Wiki "Decision regarding elective major surgery with identified patient or procedure risk factors" QUESTION

[Abayevster@gmail.com]

Does the Dr. (who is also the surgeon) suggesting surgical options and discussing the risk factors qualify as the decision for major surgery? or does the patient need to agree on this treatment course in order for it to qualify? I have searched through CMS and AMA for the past 3 hours and can't find the answer.

 

[csperoni]

The patient does not have to agree to surgery to count for risk.

From AMA guide (my emphasis added) https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

• The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment (s). This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment