Wiki Risk level for surgery

[LauraLight]

Hello! I've recently had an audit, and the auditor told me if the decision is made for patient to have surgery (patient will have general anesthesia and an abdominal incision) but the provider does not state a risk to patient, it goes into low risk category. Has anyone heard of this before? If so, can they share with me the guidelines? I have hunted and cannot find this "rule" anywhere.

It was my understanding that the guidelines written prevent someone from automatically tossing the visit up to a high category just because they are having surgery. But I've never heard of the absolute necessity to put it in a low category if the provider does not state it is risky to patient in one way or the other.

After all, I would think surgery would score higher risk than OTC meds, physical therapy, or orthotic shoes...correct?

 

[amyjph]

It's tough to say without specifics of the documentation or context of what they were talking about.
Was it condsidered minor or major surgery without patient/procedure identified risk factors? What is the type of visit and type of surgery?
If it is an elective major surgery decision without identified patient or procedure risk factors it would fall to moderate in the risk column.

 

[LauraLight]

Thank you so much for replying! I appreciate it! It was an elective major surgery; Provider documents that he discussed risks to patient but does not clarify exactly what those risks are.