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Table of Risk

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2
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We're using a new auditing sheet. Under the Diagnostic Procedures Ordered, I really need some clarification. It states under Moderate: Cardiovascular imaging studies w/contrast and no identified risk factors; under High: Cardiovascular imaging studies w/contrast w/identified risk factors. When they're referring to the risk factors, are they saying a pt with risk factors as opposed to a pt without? Could it be as simple as the physician going over the risks of the procedure with the pt? Would really love some input.

Thanks!

Hope Townsend
Auditing and Authorizations
Inland Cardiology Billing
(509) 847-1557
(509) 462-3146 fax
 

LindaEV

Expert
Local Chapter Officer
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437
Location
Kansas City, MO
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When talking about RISK, it is the risk to the patients health. This means the patient would have risk factors to make the procedure more risky.
 

RebeccaWoodward*

True Blue
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3,126
Location
North Carolina
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I agree with Linda. The guidelines state:

"Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented."

A patient who suffers from COPD, DM and obesity will be at a higher risk than someone who is athletic with a clean bill of health in need of a total knee replacement.
 

rlohearn

Contributor
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16
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So, along these lines, would anyone mind elaborating on elective major surgery with vs. with no identifiable risk factors?

If the procedures are inherently risky in and of themselves (as in neurosurg), would that be considerable as an identifiable risk factor? Or does this phrase just refer to the patient's comorbidities?

Thanks in advance for anyone's input!
 
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4,466
Location
Milwaukee WI
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Risk Factors

Identifiable risk factors refers to co-morbidities and MUST be spelled out by the physician in order to get credit for the higher level of risk.

Let's say, for argument's sake, that the patient is your relative and you KNOW the patient has DM2. If the surgeon recommends an I&D of an abscess and makes no mention of the additional risk due to these conditions, then it is a low risk (minor surgery without identified risk factors). If the surgeon documents the co-morbidities as added risk, then you have moderate risk.

We are coders, we are not physicians. Even when we "know" that something is true, if the physician has not documented it, we cannot code it.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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