Wiki Decision for surgery

[karenpez]

If a provider makes a decision for surgery but does not document specific patient risk factors, what level of risk are you giving the provider credit for?

 

[natashalage]

I would say, that you need column 1 for dx and column 2 for data. The decision for surgery can be moderate or high risk, it all depends what you have in column 1 and 2.

 

[amyjph]

It depends. From your statement, we can't give a black/white answer. Is it minor or major surgery? Are you only asking about the column for risk? If talking only about the risk element, and the surgery is considered major, and there are no specifically identified patient/procedure risk factors, it would most likely be moderate for that element.

 

[karenpez]

It depends. From your statement, we can't give a black/white answer. Is it minor or major surgery? Are you only asking about the column for risk? If talking only about the risk element, and the surgery is considered major, and there are no specifically identified patient/procedure risk factors, it would most likely be moderate for that element.

I should have expanded my explanation for the question. Recently had an auditing company state that if a provider makes decision for a procedure and does not document specific patient risk factors, they will not give credit for decision for surgery (moderate risk) they are giving low risk. Examples would be if physician and patient decide to proceed with a procedure and if the physician does not document specific patient risks such as increase for bleeding to due medication, or due to high blood pressure patient is at increased risk for stroke they will not give moderate risk credit. Just interested in other opinions on this

 

[amyjph]

If it is a decision for elective, major surgery without identified patient or procedure risk factors, that goes against the E/M guidelines. It would be moderate. If major, elective with risk identified it would push to high.
If talking minor, it would only be moderate if there were risk factors specifically to the patient/procedure documented. Not just general risks of any procedure.
It's not just a procedure, it would have to be identified as major/minor. It is clearly defined in CPT.
Depends on the context of their statement and what type of procedure.

 

[danareeves]

what if the patient doesn't meet criteria for medical necessity, surgery risks and benefits are discussed and the patient elects to wait - still moderate because discussion and documentation present?

 

[amyjph]

what if the patient doesn't meet criteria for medical necessity, surgery risks and benefits are discussed and the patient elects to wait - still moderate because discussion and documentation present?

It depends on the documentation. You wouldn't look at it from the perspective of whether or not the carrier would pre-auth or LCDs would cover it or not. That is a separate issue. You would look at it from the perspective of the clinical documentation. If the provider discussed major surgery because they think that is what needs to be done, it is documented what was discussed, and there was shared decision making with the patient and they decide to wait, it would most likely be moderate. However, it can't just be a cloned template that is in every single note like we see a lot of times. For example, in an ortho practice with total joint docs, I have seen where every single knee OA note says the same blurb at the end with the progression of treatments listed and ends with what is usually the final option of TKA. That's not specific to the patient. Half the time they did not really even discuss it yet because they are at the PT and OTC med stage, for example. It's really note and documentation dependent.