Wiki Risk of Complication and or morbidity of pt management low or moderate?

[wynonna]

My question: Re: MDM for Decision regarding elective major surgery or minor surgery with risk factors:
When an ENT surgeon has multiple conversations about a surgery with a patient including discussing risk factors for a minor surgery, how many times can this be counted towards moderate level decision making? (in the case when he discusses surgery and patient opts out or considers it, and then patient comes back months or a year later and is advised on same surgery again by same MD for same dx? Assuming the patient's risk factors haven't changed?

 

[Cheezum51]

As a provider, I would think this would count again in the scenario you discuss where the patient returns months or a year later. The provider still has to determine if they would recommend surgery and discuss it with the patient. If the patient defers again, that's their choice based upon the information provided. Of course the provider needs to document the discussion again. For visits spaced out as your example, the provider also has to determine if the risk factors have changed over the time interval.

On the other hand, if the patient was returning every couple of weeks or monthly, I don't personally think that decision for surgery should count, assuming the risk factors haven't changed in that short period of time. If something did change significantly, even in that short time, then I would imagine it would count in the MDM Risk category.

Tom Cheezum, OD, CPC, COPC