Neurosurgery Coding Alert

Question: Our provider recently spent some time discussing the risk factors for major surgery. At the end of the discussion, the patient did not agree that surgery was the best treatment for them at that time. Does this qualify as a high risk under the complications and/or morbidity or mortality of patient management element of medical decision making (MDM) in the new office/outpatient evaluation and management (E/M) guidelines?

Michigan Subscriber

Answer: Yes. Per the new office/outpatient E/M MDM guidelines, calculations for the level or risk include “the possible management options selected and those considered, but not selected, after shared MDM with the patient and/or family” (emphasis added).

The guidelines continue with an example that states, “a decision about hospitalization includes consideration of alternative levels of care.” So, several examples in the high risk of morbidity level of MDM use the word “decision,” which can be taken to mean the decision could be positive or negative.