Wiki Giving credit for treatment/diagnostics considered

[Queizati]

Our physicians regularly document in their assessment and plan management options such as:

"If no improvement with the above plan, consider LESI."
"Can consider SI joint injections based on findings on imaging"
"Consider MRI of the lumbar spine as indicated" (If an x-ray is ordered first during the visit)
"To assist with procedural and surgical decision making, an MRI and X-ray will be obtained)

Is this enough to give credit for the MDM component of Risk of Complications and/or Morbidity or Mortality of Patient Management using AMA's definitions of Risk and Risk of Complications and/or Morbidity or Mortality of Patient Management?

AMA definitions:
Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization.

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.

 

[csperoni]

The AMA guide does specify options considered but not selected. That being said, specifically with regards to surgery, if my clinicians are not discussing the type of surgery, risks of surgery, then I would not count that as surgery risk.
For example, in the 4th statement "to assist with surgical decision making, MRI & Xray will be obtained" If they are not specifying the surgery, even what type of surgery, or discussing the risks, I wouldn't count that as decision regarding surgery. I would count the risk of the xray and MRI.

 

[Robyn07]

I agree with the above response. I would also caution them on using templated data such as noted above.

 

[Queizati]

The AMA guide does specify options considered but not selected. That being said, specifically with regards to surgery, if my clinicians are not discussing the type of surgery, risks of surgery, then I would not count that as surgery risk.
For example, in the 4th statement "to assist with surgical decision making, MRI & Xray will be obtained" If they are not specifying the surgery, even what type of surgery, or discussing the risks, I wouldn't count that as decision regarding surgery. I would count the risk of the xray and MRI.

Thank you for your feedback. Counting the ordering of an X-ray and MRI into the category of Data Analyzed (as two unique tests) and counting it in the category of Risk of Complications and/or Morbidity or Mortality of Patient Management- would this be considered 'double dipping'?

 

[csperoni]

No, counting the order/review and counting the risk of the test are 2 separate elements.