Wiki Number of times Decision for Surgery can be used

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Joymissy85

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I am at odds with a co-worker in a discussion we are having. Patient is seen in Plastic Surgery Residency Clinic. She has multiple visits for example. She is seen on 1/7/21 for the initial evaluation of for example of breast reduction and it was decided at that time to proceed with the surgery. The patient comes in again in 3 months for a follow-up of discussion of breast surgery and still wants to proceed with surgery. Co-worker feels that the decision for surgery can be used at both the initial visit and at the follow-up visit.

How many times can the decision for surgery be used for the same surgery?
 
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I don't know of any specified limit, but I interpret the AMA 2021 E/M guidelines that the decision for surgery risk may sometimes be counted more than once.
Specifically:
"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."

Example: Progressively worse knee pain and documented that surgery is considered but not selected at one visit (patient opts for more conservative treatment with Rx and PT.) Returns in 8 weeks: pain is not improving, and now is proceeding with surgery. I would count the decision for surgery risk twice in that situation.

For your case, I think it depends why the surgery was not scheduled and why that patient is returning. If patient's medical history changed in the interim (for example, recently diagnosed with MS) and needs to discuss how this impacts whether or not she has the surgery, I would count it twice. If it was that she forgot the postop instructions, I would not count it twice. If she realized after going home that she forgot to provide a relevant aspect of her history, and she returns to discuss that additional information, I would count it twice. I would use the dividing line of whether or not to count it again as whether or not the clinician needed to make another management decision.
 
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Joymissy85 said:
I am at odds with a co-worker in a discussion we are having. Patient is seen in Plastic Surgery Residency Clinic. She has multiple visits for example. She is seen on 1/7/21 for the initial evaluation of for example of breast reduction and it was decided at that time to proceed with the surgery. The patient comes in again in 3 months for a follow-up of discussion of breast surgery and still wants to proceed with surgery. Co-worker feels that the decision for surgery can be used at both the initial visit and at the follow-up visit.

How many times can the decision for surgery be used for the same surgery?
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In this case after the Jan 7th visit there needed to be a authorization sent to the insurance company to get approval. Once the approval came in then the patient returned to schedule the surgery. Nothing had changed other than approval was given by the insurance company to proceed with scheduling the surgery.
 
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I would absolutely NOT count this again.
Just curious - we don't have the patient return to schedule the surgery. At the visit where we determine surgery is needed, the patient is consented, given instructions, etc. The surgical coordinator does not need the patient there to schedule the surgery. It will be scheduled within a few days for whatever day/time works on our hospital block time and patient preference, and insurance authorization will be obtained. If the patient has additional questions, she will speak with the PA over the phone. If the patient has significant concerns/questions/changing her mind, we will then have her come for another visit with the physician. I do not understand why the patient needed a second visit at all in your situation. It does not appear to be medically necessary.
 
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I know this thread is old, but I have a similar situation. The provider saw the patient and was interested in ordering surgery, but he needed to consult with one of her specialist before deciding. He spoke with the specialist a few days later, then ordered the surgery. Can the decision for surgery be counted in MDM for the E/M, or no because it was on a different date? Thank you!
 
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As always, it all depends on the documentation.
I would count decision regarding surgery at the E&M IF the discussion regarding the procedure and risks/benefits/alternatives was done with the patient.
If at the E&M, all he did was say "hey, let's consider surgery, but I want input from your cardiologist." and didn't discuss what surgery, or go into any real discussion/decision making, then I would not count decision regarding surgery.

Remember it's not necessarily decision to have surgery, but rather a decision regarding surgery.
 
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csperoni said:
As always, it all depends on the documentation.
I would count decision regarding surgery at the E&M IF the discussion regarding the procedure and risks/benefits/alternatives was done with the patient.
If at the E&M, all he did was say "hey, let's consider surgery, but I want input from your cardiologist." and didn't discuss what surgery, or go into any real discussion/decision making, then I would not count decision regarding surgery.

Remember it's not necessarily decision to have surgery, but rather a decision regarding surgery.
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Thank you, the way you explained that makes a lot of sense.
 
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