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christienrandy

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If a provider discusses surgery and the patient declines the surgery, Would this still fall under a level 4 office visit? I am getting mixed answers. I interpret the AMA's "consideration" of surgery to mean discussion. Thank you!
 
Hi there a couple of things:
1. The mental work of considering a treatment doesn't necessarily require a discussion with the patient, but documentation of the discussion is certainly evidence that the provider considered the procedure. However, a the provider might consider a certain treatment or procedure for a patient but decide it isn't appropriate and never discuss it with the patient. They just need to put it in their note.
2. The MDM related to considering the risk of a procedure might change the level of risk for the visit, but it won't automatically be moderate or high risk and it will never automatically set the entire level for the visit.
 
IMO, the discussion of the surgery and consideration of risks/benefits will have taken place as if the patient is moving forward with the procedure; thus the work was done. That the patient declines the surgery doesn't negate that the provider considered, discussed and recommended the surgery. I always give credit if the provider recommends treatment even if the patient declines altogether. And if you think about it (although it's tough to quantify for purposes of MDM), wouldn't declining treatment increase the patient's overall risk?
 
Pam Warren said:
IMO, the discussion of the surgery and consideration of risks/benefits will have taken place as if the patient is moving forward with the procedure; thus the work was done. That the patient declines the surgery doesn't negate that the provider considered, discussed and recommended the surgery. I always give credit if the provider recommends treatment even if the patient declines altogether. And if you think about it (although it's tough to quantify for purposes of MDM), wouldn't declining treatment increase the patient's overall risk?
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I agree! Do you have any guidance on how lengthy a risks and benefits discussion should be? Thank you!
 
Other than the provider potentially documenting time for determining the level of E&M code, there's no time criteria for any element of the discussion. What is important is for the provider to note that the discussion took place, the pros/cons of the surgery, other alternatives, and that the patient declined and why (if known).
 
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