Wiki E&M Medical Decision Making

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I am looking for clarification on whether or not a provider reviewing multiple treatment options with the patient counts as a “decision for surgery” as long as one of those options is surgery, regardless of the patient's current presentation or a definitive recommendation by the Provider.

Example:
“I discussed various treatment options including OTC meds, physical therapy or surgery. This condition may also resolve on its own 50% of time. All the patients questions were answered. Patient will take a wait and see approach. Patient will follow-up as needed.”
 
If the type of surgery is not mentioned, nor the risks, then the highest that could possibly be counted is minor surgery without identified risks which would fall into low risk category.
If the provider really had a true discussion about the type of surgery, and the risks, then that needs to be documented better. A statement like this to me means the provider probably mentioned surgery was an option, but did not really have any in depth discussion or thought process about it.
A statement like "a total laparoscopic hysterectomy would be standard treatment to manage the condition. However, discussed with patient that her currently uncontrolled diabetes puts her at an elevated risk to undergo a major surgery or anesthesia at this time and would significantly slow healing. I recommend alternate treatment with Mirena IUD while she continues care with endocrinologist to get diabetes under control. Will re-evaluate in 2 months." In this case, the physician's final recommendation is a prescription, but did evaluate and consider a major surgery with identified patient risks, so I would count as high risk.
 
My Providers keep putting E/M codes on claim along with Mohs surgery using modifier 25 Example: 99213.25 or 57 and 17311 The documentation for the Mohs was done correctly and the Doctor decided to do extensive closure see note: Would this qualify for E/M code? I
Plan: Lab Reports Reviewed. Labs Reviewed: outside pathology reviewed by dermatologist Summarized Results: BCC-Right Nasal Ala Plan: Separate and Identifiable Documentation. This patient has a complex surgical defect resulting from a procedure (Mohs surgery) performed earlier today that was medically necessary in order to completely remove a malignant tumor. This defect requires a major surgical procedure (flap and/or graft) for reconstruction. The medical decision making and counseling involved in deciding to perform a major reconstructive surgical procedure address the problem of the surgical defect and constitute a separate and identifiable evaluation and management service. Plan: Surgical Decision Making. After thorough evaluation of this patient?s surgical defect resulting from tumor extirpation using Mohs micrographic surgery and consideration for the patient?s needs, expectations and wound care capabilities, the decision was made to perform a major reconstructive procedure. The evaluation, examination and discussion involved in making this decision are a done in addressing a surgical defect resulting from a medically-necessary tumor extirpative procedure performed earlier today (Mohs surgery) and constitute a separate and identifiable.

I have soon that deciding a closure is considered part of the surgery the only extra coding is used for the closure that was done. Any help would be appreciated.
 
This sounds like a ganglion cyst of the wrist. In the fingers and knee (Baker's) those don't tend to go away on their own like a wrist cyst. The only time surgery is seriously considered as a treatment option is when the cyst is painful, restricting movement and has not gone away on its own. In what little info that has been provided, it does not sound like surgery was really considered as a treatment option. A possible future outcome, yes. But not a serious option at this point.
 

fmshero1 - That is a toughie. My recommendation is to bill with Dx T88.9XXA "Complication of surgical and medical care, unspecified." I believe you may have a case of billing an office visit using modifier -57 if it's a major procedure (90 day global.) Can you share the Dx's of the E/M? That may aid us in giving you guidance.​

 
I am looking for clarification on whether or not a provider reviewing multiple treatment options with the patient counts as a “decision for surgery” as long as one of those options is surgery, regardless of the patient's current presentation or a definitive recommendation by the Provider.

In the situation you're describing, I would not consider that a decision for surgery, especially since in your example the provider explicitly states the patient is using a "wait and see approach". The only time I would use mod 57 is when, like csperoni mentioned, risks and complications are reviewed, and the surgery is actually scheduled or planned, or in the case of inpatient and ED the surgery is actually performed that same day.
 
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