Wiki MDM for rectal prolapse

[Colliemom]

Hey,

if you were determining MDM, what level of risk would you assign for a patient with a symptomatic rectal prolapse? The provider is recommending surgical rectal prolapse repair. He thinks this is high risk, and I'm wondering if it qualifies or if it would be moderate.

What do you all think? Would rectal prolapse be an "acute illness/injury that poses a threat to bodily function" (high risk) or just "acute illness with systemic symptoms" (moderate risk)?

 

[thomas7331]

Based on the information you've given, I would assign moderate level risk for the management option of major surgery with no identified risk factors. If the provider feels this is a high risk, I think there would need to be something in the documentation to support why this is, beyond just the diagnosis.

 

[thelton]

Does the patient have chronic conditions or a co-morbidity that would make the surgery high-risk? That is something the physician would have to determine and document.