Wiki 99213 or 99214?

[RebeccaMoney]

Pt has 2 trigger fingers that are chronic. Treated with injections in the past but pain has returned over the last 4 months. Surgery recommended. Risks are discussed in detail including pain, bleeding, infection, damage to neurovascular structures, and risk or anesthesia.
Are all decisions for surgery going to be level 4? I have one doctor that feels that some decisions for surgery are level 3.
Any thoughts? Thanks,

 

[jkyles]

Hi there, the treating provider determines risk based on the patient and procedure. There isn't an automatic level of risk associated with a decision for surgery. From the guidelines:

Surgery–Risk Factors, Patient or Procedure: Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.

 

[csperoni]

As @jkyles@decisionhealth.com stated, there is never an automatic level for anything. That being said, from my experience, decision for surgery often meets level 4 on even problems and data.
1) Problems. The problem is likely not chronic stable or acute uncomplicated. If it was, you would probably not be doing surgery on the patient. Likely level 4.
2) Data. All my surgeons order PST labs prior to surgery. CBC, CMP, PT/PTT/INR, covid swab, etc. Once you have 3 tests ordered, you are at level 4 for data.
3) Risk. Low level regarding surgery is only for minor surgery without identified risk factors. I suppose if your surgeon is not discussing the risks (or not documenting them), then you would be level 3. Even minor surgery comes with risk, and if properly documented, would be level 4. Remember another examples of level 3 is OTC meds. A minor surgery with documented risk of damage to neurovascular structures certainly seems more risk than "take Tylenol and RTO in 2 weeks."
If you have level 4 for problems and level 4 for data, even level 3 risk still results in 99214.