Wiki Decision regarding surgery

Cheezum51

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I've had someone ask me a question about who gets credit for the decision for surgery, in respect to Moderate Risk for MDM.

Here's the scenario: I'm an optometrist and see a patient for an eye exam with complaints of significant vision problems which, after examination, are due to cataracts. I discuss the pros and cons of cataract surgery with the patient and feel they are a good candidate for surgery and then refer the patient to a cataract surgeon.

Since I'm not actually doing the surgery but evaluating the patient risk factors for surgery from my examination, do I get credit for the "decision regarding major surgery without identified patient/procedure risk factors", which allows me to have a Moderate Risk level for coding? Or, is the surgeon the only provider who can get credit for that?

I would imagine a similar situation for an FP would be a patient with chronic tonsillitis and the FP refers them to a surgeon for a tonsillectomy.

If anyone has any documentation on this type of scenario, that would be very helpful.

Tom Cheezum, OD, CPC, COPC
 
I haven't seen this situation specifically documented, but I can share my thoughts. Based on my understanding of the guidance, since the decision for surgery is listed under risk and in the category of 'management options', I have counted that toward MDM when it is recommended by the provider who is actually going to be performing the procedure since they are the provider who making that final recommendation and decision - they are the one who will be managing that treatment and assuming the risk. When the provider is simply referring the patient to a surgeon for evaluation, I'll usually count that in the 'number of diagnosis and treatment options' section (e.g. as an extra point for 'additional workup'). Since the guidance for that section of MDM originally stated that the "need to seek advice from others is another indicator of complexity of diagnostic or management problems", I've taken that to mean that consultations and/or referrals to specialists fall into this category and not to the risk category.

So for a similar example, if a PCP determines that a patient has a hernia and refers them to a general surgeon, I would not give the PCP the risk credit for the surgery since they are deferring that decision to the surgeon, but I would give credit for the referral itself. Of course as will as all of E/M, this tends to be subjective and other auditors may handle it differently. But I hope that makes sense and helps some.
 
I haven't seen this situation specifically documented, but I can share my thoughts. Based on my understanding of the guidance, since the decision for surgery is listed under risk and in the category of 'management options', I have counted that toward MDM when it is recommended by the provider who is actually going to be performing the procedure since they are the provider who making that final recommendation and decision - they are the one who will be managing that treatment and assuming the risk. When the provider is simply referring the patient to a surgeon for evaluation, I'll usually count that in the 'number of diagnosis and treatment options' section (e.g. as an extra point for 'additional workup'). Since the guidance for that section of MDM originally stated that the "need to seek advice from others is another indicator of complexity of diagnostic or management problems", I've taken that to mean that consultations and/or referrals to specialists fall into this category and not to the risk category.

So for a similar example, if a PCP determines that a patient has a hernia and refers them to a general surgeon, I would not give the PCP the risk credit for the surgery since they are deferring that decision to the surgeon, but I would give credit for the referral itself. Of course as will as all of E/M, this tends to be subjective and other auditors may handle it differently. But I hope that makes sense and helps some.
I understand your line of thinking and don't necessarily disagree with it being a valid interpretation of the guidelines. Let me give you mine.

If a patient is seen by a PCP for a problem and the PCP diagnosis the cause of the problem and also determines that the only solution to the problem is surgery, shouldn't the PCP be given credit for making the decision for some level of surgical intervention, shouldn't they be given credit for the decision under the Risk category?

I can see your scenario in a situation where the cause, extent and solution of a problem may be unclear and the referral to a surgeon is made and they then do further testing, say for a knee or back injury, to determine if surgical intervention is required.

In my situation as an eye doctor, if a patient has cataracts which are affecting the daily activities or safe driving for a patient or I diagnose a patient with a retinal detachment, I know they need surgical intervention and refer them to the appropriate type of ocular surgeon who then determines what type of surgical procedure is best to resolve the problem.

In that situation, I feel like both providers would receive credit for the surgery decision. Me, for the original diagnosis and determination that surgery is the only way to treat it and the surgeon for determining what surgical procedure is best.

Tom Cheezum, OD, CPC, COPC
 
I understand your line of thinking and don't necessarily disagree with it being a valid interpretation of the guidelines. Let me give you mine.

If a patient is seen by a PCP for a problem and the PCP diagnosis the cause of the problem and also determines that the only solution to the problem is surgery, shouldn't the PCP be given credit for making the decision for some level of surgical intervention, shouldn't they be given credit for the decision under the Risk category?

I can see your scenario in a situation where the cause, extent and solution of a problem may be unclear and the referral to a surgeon is made and they then do further testing, say for a knee or back injury, to determine if surgical intervention is required.

In my situation as an eye doctor, if a patient has cataracts which are affecting the daily activities or safe driving for a patient or I diagnose a patient with a retinal detachment, I know they need surgical intervention and refer them to the appropriate type of ocular surgeon who then determines what type of surgical procedure is best to resolve the problem.

In that situation, I feel like both providers would receive credit for the surgery decision. Me, for the original diagnosis and determination that surgery is the only way to treat it and the surgeon for determining what surgical procedure is best.

Tom Cheezum, OD, CPC, COPC
Yes, I do think that the PCP or physician making the referral should be given credit for risk in the category of the presenting problem because a problem that may require an intervention does involve a higher level of MDM, but just not in the risk category of the 'management options selected' when the surgical plan of care to manage the patient will be implemented by the surgeon. My reasoning is that it is the surgeon and not the PCP who is exposing the patient to risk. (It's for this very reason that a surgeon's malpractice costs are higher than a general practitioner's.) The PCP does get credit for management risks when prescribing medications, for example, because the patient is exposed to those risks in the course of the drug treatment regimen ordered by the PCP.

Of course, all that said, the E/M guidelines are self-admittedly only just that: "because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk." In my experience, every patient and plan of care is unique and there will never be a perfect way to capture the nuances and complexity in a single set of rules or 'points' that can be assigned. So I think there will always be different interpretations of how to code E/M levels and I'm not sure there's any way to get around that, no matter how detailed we try to make the guidelines.
 
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As one of my coding acquaintances says, "If you can't deal with gray areas, coding may not be the profession for you."

Tom Cheezum, OD, CPC, COPC
I totally agree. I tell coders we should celebrate the grey areas - if it weren't for those, then coding would very soon be done entirely by computers.
 
A similar situation in my practice; The physician takes the time to review the surgical option for the treatment of a condition, then the patient decides not to go through with it. I have not been counting that at the "decision for surgery" because the decision was not made. However, the physician still wants credit for the time and effort put in. I suggested using the time based E/M instead of the risk/MDM based. Would you agree?
 
A similar situation in my practice; The physician takes the time to review the surgical option for the treatment of a condition, then the patient decides not to go through with it. I have not been counting that at the "decision for surgery" because the decision was not made. However, the physician still wants credit for the time and effort put in. I suggested using the time based E/M instead of the risk/MDM based. Would you agree?
Key words "The patient decides not to go through with it". The physician has identified the need for surgery. The patient can decide to either have the procedure or not, but the provider identified the need for surgery. You should give that provider credit for that.
 
So you are saying that when I'm looking at the table I can check the "decision regarding minor surgery" or "decision regarding major surgery" with or with out risk, regardless of the patient's choice?

Also, what is the difference between "Minor surgery with no identified risk factors" and the wording "decision regarding" that we see in the higher levels of risk on the table?
 
So you are saying that when I'm looking at the table I can check the "decision regarding minor surgery" or "decision regarding major surgery" with or with out risk, regardless of the patient's choice?

Also, what is the difference between "Minor surgery with no identified risk factors" and the wording "decision regarding" that we see in the higher levels of risk on the table?
That's the whole point, the patient does not make the decision that they need surgery, the surgeon does. The surgeon evaluated the patient and decided on the treatment plan, not the patient. Regarding the decision for surgery they all state either with risk factors or without. Risk factors are usually medical conditions that can make operating on the patient more risky. Patient with heart or lung problems are going to be at a greater risk having surgery than healthy patients. Also blood clotting can come into play. If the patient has medical conditions that can increase the risk for a negative outcome, the doctor has to be given credit for that medical decision making.
 
I agree. If the physician is making a decision about surgery, then that counts, regardless of whether or not the patient chooses to proceed. As with everything, this needs to be documented. If the physician simply writes "Surgery vs medical management; pt prefers medical management." without indicating what the surgery was, any risks, etc, then I wouldn't count risk for surgery. (I know, this would be bad documentation but you can't credit what's not documented.)
From the 2021 AMA E/M guidelines:
The risk of complications and/or morbidity 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 MDM 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.
 
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