Wiki 2021 E&M

[NEOSM507]

Good morning,

Hoping my ortho peers can help me! I need some clarification with the language used in the risk column for a level 4 E&M. Specifically when they refer to the "with/without identified patient or procedure risk factors". Why would a minor surgery discussion count with but a major surgery discussion count without? Every surgery (minor or major) has risks that are discussed.

Decision regarding minor surgery with identified
patient or procedure risk factors

Decision regarding elective major surgery without
identified patient or procedure risk factors

Thank you

 

[beulastella]

Yes Agree,

But that when the major surgery is performed in a healthy patients with same ortho complaint then it would be tracked to without any identified patient (Comorbid) or procedure risk factors.

Decision regarding minor surgery with identified patient or procedure risk factors -
Decision regarding elective major surgery without identified patient or procedure risk factors

Decisions regarding minor or major surgery were expanded to address not only patient risk factors but also the risk factors of procedures. Documentation should include the procedural risks, discussion with the patient/family concerning risks in addition to any patient comorbidities, and how they impact decision-making or may impact outcomes as outlined earlier.

 

[chelseajaustin]

Yes Agree,

But that when the major surgery is performed in a healthy patients with same ortho complaint then it would be tracked to without any identified patient (Comorbid) or procedure risk factors.

Decision regarding minor surgery with identified patient or procedure risk factors -
Decision regarding elective major surgery without identified patient or procedure risk factors

Decisions regarding minor or major surgery were expanded to address not only patient risk factors but also the risk factors of procedures. Documentation should include the procedural risks, discussion with the patient/family concerning risks in addition to any patient comorbidities, and how they impact decision-making or may impact outcomes as outlined earlier.

What would constitute "procedure risks factors?"