E/M Leveling on a Recurrent Keloid

Question:

The patient has a recurrent keloid following surgical excision and is largely asymptomatic, with only occasional pruritus and burning. Does this fall under low or moderate medical decision making?

Answer:

Based on the condition alone, a recurrent keloid that is stable and only mildly symptomatic would generally meet Low MDM under the “Number and Complexity of Problems Addressed” element. However, the final MDM level cannot be determined without considering the other two MDM elements: data reviewed and the risk of treatment and management. If no data is reviewed and management is limited to observation, conservative measures, or a minor procedure with no risks the overall MDM would remain Low.

*This response is based on the best information available as of 03/05/26.