Wiki minor/major surgery "with identified patient or procedure risk factors"

[MelodyCPC]

We are having some internal discussion regarding how to accurately assess the level of risk of patient management when a patient has an injection or RFA (minor surgery) ordered. The guidelines state "Decision regarding minor surgery with identified patient or procedure risk factors". We all know that there are inherent risks associated with procedures like injections....bleeding, infection, nerve damage. If a patient doesn't have any patient specific risk factors (such as age or a comorbidity), but the provider states "discussed risks and benefits regarding the injection with the patient as well as possibility of bleeding, infection, nerve damage, and patient agrees to the procedure", should this be analyzed as moderate risk since the provider stated the procedure risks?

 

[Pam Warren]

No. The discussion of the standard risks and benefits are part of informed consent for any procedure performed. The provider would need to separately document the patient-specific risks; i.e. anticoagulation therapy, diabetes, for example in order to achieve a higher level of risk to calculate MDM.

 

[Orthocoderpgu]

Before any surgery or procedure the provider will always discuss the potential risks of that procedure to the patient. That does not automatically mean that the risk increases for the procedure being done, just that the patient is aware is all. If the patient does have a "risk factor" such as aticoagulation issues, heart problems, lung issues, these need to be documented as well. This would include being documented in the procedure note.