Wiki Surgery Discussion

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arkolab

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Lancaster, WI
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Is it appropriate to count decision regarding an elective major surgery under the risk column when the provider goes over risks and benefits of different treatment options but chooses not to proceed with surgery at this time?

For example:
ASSESSMENT: Degenerative arthritis of proximal interphalangeal joint of little finger of left hand (primary encounter diagnosis)
Chronic wrist pain, left
Mass of wrist, left
Digital mucinous cyst of finger

PLAN: I discussed with patient the diagnosis and my impression, its etiology, and different workup and treatment options, including wrapping and surgical excision, we discussed arthroplasty and injection as well as risks. We discussed different management options and the risks/benefits of each. We discussed expectations and prognosis. We discussed the joint and cyst considerations as well as recurrence. After this detailed discussion, the patient is electing for injection which is performed.
 
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See resources below, it includes possible options even if they are ultimately not decided on. HOWEVER, I would expect to see a more robust and detailed note than the snip you have above regarding the discussion about arthroplasty and why it was decided not to do that. Because, when someone is referred to ortho surgery, almost every single note it going to have a "canned" macro template where they state "we discussed blah blah blah" but the example above is not patient, procedure, or risk specific. They are a surgeon, of course they will tell the patient about surgery options. The example above states, "after detailed discussion", ok what was specifically discussed? Not documented. The provider must elaborate more. What was the thinking process, what was the reason the surgery was not decided on? What risks did they talk about? Why did the patient decide on injection?


"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. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment."


A patient is referred to a surgeon for possible major surgery, and the surgeon decides that surgery is not appropriate based on their evaluation of the patient. Can this still be considered a decision for surgery under the “risk” element of MDM?

Yes, this scenario applies to the MDM element “risk of complications and/or morbidity or mortality of patient management”—which includes both possible management options selected as well as those considered but not selected—after shared MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Shared MDM involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options.

Risk and Complications of Patient Management​

Q1. I discussed possible surgery, hospitalization, etc. as listed in the risk category. Can I consider these discussions when the final decision is no to those options?
A1. Yes, as you discussed and came to a decision on those options.

 
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