Queizati
Networker
Hello,
I was wondering if I could get some input regarding giving credit for possible management options and tests considered when the physician is considering these options pending patient response.
CPT Guidelines:
Here are some examples of what the notation looks like that I'm coming across:
1) "If the patient has not improved with the above therapies (PT, OTC meds) may consider MRI for further evaluation."
2) "If the patient's pain is without continued improvement may consider ESI/MBB/TFESI."
3) "Discussed possible management options with the patient including PT/OT, corticosteroid injections, and surgery should all other management options fail."
I'm conflicted over the fact that these are possible management options/tests, but they are not being recommended to the patient at the point in time of the visit. I would appreciate any thoughts or feedback on how you would count this if you were reviewing a note.
I was wondering if I could get some input regarding giving credit for possible management options and tests considered when the physician is considering these options pending patient response.
CPT Guidelines:
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.
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
Here are some examples of what the notation looks like that I'm coming across:
1) "If the patient has not improved with the above therapies (PT, OTC meds) may consider MRI for further evaluation."
2) "If the patient's pain is without continued improvement may consider ESI/MBB/TFESI."
3) "Discussed possible management options with the patient including PT/OT, corticosteroid injections, and surgery should all other management options fail."
I'm conflicted over the fact that these are possible management options/tests, but they are not being recommended to the patient at the point in time of the visit. I would appreciate any thoughts or feedback on how you would count this if you were reviewing a note.