Wiki Decision regarding surgery with identified patient or procedure risk factors

[Queizati]

If a physician decides an injection of the joint is the next step in treating a patient for their pain would you give credit for ‘decision regarding minor procedure with identified risk factors’ for the following statement:

“The purpose, risks, benefits, alternatives were discussed. The patient agreed to proceed.”

Would this be enough to justify an identified risk(s)?

 

[jkyles]

Hi there,

That isn't enough. The risk must be specific to the patient, relevant to the procedure and clearly documented by the treating provider to show their medical decision-making.

More here: https://www.aapc.com/discuss/thread...ors-for-e-m-with-procedure.192053/post-526302

 

[Queizati]

Hi there,

That isn't enough. The risk must be specific to the patient, relevant to the procedure and clearly documented by the treating provider to show their medical decision-making.

More here: https://www.aapc.com/discuss/thread...ors-for-e-m-with-procedure.192053/post-526302

Thank you! It would be so helpful if the AMA could include this information in the E/M guidelines in the CPT manual. It would be very useful in explaining to physicians that a decision for any minor procedure does not automatically equate to a moderate risk for every single encounter.

 

[Cwirtalla]

Would a joint injection even be considered a minor procedure? I don't usually view them as a minor procedure.

 

[amyjph]

There was a good discussion about it in here: https://www.aapc.com/discuss/thread...drug-management.191241/?view=date#post-523934

If you search in the forums for the topic and key terms like 20610, joint injection, risk, etc.