DECISION FOR SURGERY

Karalea88

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Lake Charles, LA
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If a provider documents "We discussed the risks and benefits of a corticosteroid injection" does this meet the documentation requirement for Decision for minor surgery with risk factors? OR does the provider need to include the risk and benefits in the documentation to support decision for surgery?
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haraml7

Networker
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Did he perform the shot that day, because if he did then you would not count that as an element, since the reimbursement for this minor procedure is in the actual procedure being performed. If I am understanding the question correctly.
 

Karalea88

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Lake Charles, LA
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Yes, decision was made during visit to perform injection that day. Provider wants to bill 99214 but I suggest 99213. 68 year old patient with MODERATE problem, minimal amount and/or complexity of data, and low risk factor since documentation does not support any co-morbidities or conditions that would warrant a higher risk factor.
 

Karalea88

Contributor
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Lake Charles, LA
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Did he perform the shot that day, because if he did then you would not count that as an element, since the reimbursement for this minor procedure is in the actual procedure being performed. If I am understanding the question correctly.
I understand that if procedure was done the same day as visit then we would not give credit for MDM but is it necessary for the provider to include the list of risk factors in the note itself or can they just document "Risk and benefits discussed' for outpatient/inpatient surgery?
 

vinessachilders

Networker
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Pretty sure the provider does not need to list the risk and/or benefits discussed. Just the notation is support.
 

mihill

New
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Agreed, provider does not need to list all the risks/benefits; only document they were discussed.
 
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