jhaleycoder
Networker
Hi Everyone-
I wanted to reach out for help. I want to educate my providers on when TO and NOT to use a level 5. I am finding some providers are using cloned statements adding time when decision of surgery is made. They are adding a cloned statement for risk factors of surgery. How can I explain that a level 5 isn't warranted for every surgery and time needs to be justified. Below is an example:
I had a long discussion with the patient regarding the natural history of knee degenerative joint disease. I used the patient's own imaging as well as bone models to aid in our discussion. We discussed conservative treatment options including OTC medications/NSAIDs, physical therapy and intra-articular corticosteroid injections. We also discussed surgical treatment options in the form of joint replacement. At this point he has failed conservative management and his left knee pain and function are severely impacting his overall quality of life. Through shared decision making, decision was made to proceed with left total knee arthroplasty
The patient and I reviewed their chief complaint, history of present illness, radiology findings, differential diagnosis and the pros, cons, alternatives, risks, and benefits of further conservative treatment versus operative intervention. Educational tools including implant model and patient x-rays were used to discuss implant type and function. The patient remains symptomatic. They clearly understand that there is no guarantee of improvement with either treatment option, both carry risks including worsening pain. They also understand the indications and limitations of surgery and the need for post operative rehabilitation / recovery. Healing times vary greatly among patients and this was discussed. All patient questions were answered satisfactorily. Risks, benefits, and alternatives to surgery have been discussed with the patient including but not limited to bleeding and need for blood transfusion, infection, intraoperative or postoperative fracture, hardware failure, neurovascular injury, thigh or knee numbness, chronic pain and scarring, chronic tendonitis or swelling, dislocation, leg-length discrepancy, the potential need for future surgery, DVT, PE, heart attack, stroke and death. The patient demonstrates understanding and wishes to proceed. After our long discussion the final decision for surgery was made today and final paperwork including signing of the surgical consent was performed.
Greater than 1 hour was spent on direct patient care including reviewing imaging and discussing treatment options
We will schedule him for a left total knee arthroplasty. He will obtain all necessary preoperative lab work, clearances, CT scan
I wanted to reach out for help. I want to educate my providers on when TO and NOT to use a level 5. I am finding some providers are using cloned statements adding time when decision of surgery is made. They are adding a cloned statement for risk factors of surgery. How can I explain that a level 5 isn't warranted for every surgery and time needs to be justified. Below is an example:
I had a long discussion with the patient regarding the natural history of knee degenerative joint disease. I used the patient's own imaging as well as bone models to aid in our discussion. We discussed conservative treatment options including OTC medications/NSAIDs, physical therapy and intra-articular corticosteroid injections. We also discussed surgical treatment options in the form of joint replacement. At this point he has failed conservative management and his left knee pain and function are severely impacting his overall quality of life. Through shared decision making, decision was made to proceed with left total knee arthroplasty
The patient and I reviewed their chief complaint, history of present illness, radiology findings, differential diagnosis and the pros, cons, alternatives, risks, and benefits of further conservative treatment versus operative intervention. Educational tools including implant model and patient x-rays were used to discuss implant type and function. The patient remains symptomatic. They clearly understand that there is no guarantee of improvement with either treatment option, both carry risks including worsening pain. They also understand the indications and limitations of surgery and the need for post operative rehabilitation / recovery. Healing times vary greatly among patients and this was discussed. All patient questions were answered satisfactorily. Risks, benefits, and alternatives to surgery have been discussed with the patient including but not limited to bleeding and need for blood transfusion, infection, intraoperative or postoperative fracture, hardware failure, neurovascular injury, thigh or knee numbness, chronic pain and scarring, chronic tendonitis or swelling, dislocation, leg-length discrepancy, the potential need for future surgery, DVT, PE, heart attack, stroke and death. The patient demonstrates understanding and wishes to proceed. After our long discussion the final decision for surgery was made today and final paperwork including signing of the surgical consent was performed.
Greater than 1 hour was spent on direct patient care including reviewing imaging and discussing treatment options
We will schedule him for a left total knee arthroplasty. He will obtain all necessary preoperative lab work, clearances, CT scan
