Wiki risk for follow up visit, no further issues

[lhoot]

Good Morning,
I'm looking for some help in determining what the risk would be for a patient returning for a followup of hand surgery 20 weeks post op. There is no further treatment, prescriptions or issues remaining. Patient is to just continue stretching exercises and return as needed. I say it would be low, but I'm second guessing myself. If you feel it would be moderate, please provide some reasoning.
Thank you in advance for your time.
Laura

 

[moeslilmom]

I'm thinking it may even be considered minimal at this point. While the patient may have come in with an acute uncomplicated injury, since the patient had surgery and the physician is documenting the patient has no more issues and follow-up is PRN, then I would think this would now fall under a self-limited or minor problem. As for the exercises, these are simple home exercises and not under the direction and supervision of a physical therapist, so I would hesitate to group the home exercises with the physical therapy listed under the low management option, as physical therapy is usually associated with a more complicated injury than when the doctor just advises on home exercises.

Unfortunately, that is all we have to go on so it is left up to the subjective opinions of the coder. I would definitely say that at the very most it would be low. If the patient is healthy, progressing, and there are no other tests or procedures ordered, then there is little, if any, medical risk involved.

Also, unless the physician reviewed AND interpreted x-rays at this visit (to give the physician 3 data points), the minimal/low risk wouldn't matter because the total MDM level would still be straightforward anyways due to this being an established issue that is stable/improved (1 data point).

 

[lhoot]

Dawn,
Thank you so much. Your explanation was exactly what I was thinking and I'm glad to see that I was on the right path.
Laura