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Thread: Management Options

  1. #1

    Question Management Options

    AAPC: Back to School
    I work for Orthopedic Specialists and I have a Dr that always discusses surgery as an option along with conservative treatment. I am confused as to when I should give him points in the MDM for surgery. Does he get points just for discussing surgery or does it need to be the treatment plan that was decided? Here is an example from a patient with a rotator cuff tear:
    Imaging findings were reviewed along with relevant treatment options, both nonoperative and operative with their respective pros and cons. We reviewed the rx options and indications for surgery: L Shoulder scope/ SAD/ bicpes tenodesis and poss RCR; Nonoperative mgmt was also explained; he will review his options and contact us prn for further rx;
    Most of the audit forms that I have state Management options selected not discussed. What do you guys think? Does anyone have a source you can point me to for this when talking to the Dr's and management about this?
    Thanks for your help!

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Recommendation for surgery

    Some physicians are more "forceful" in making their recommendations for surgery than others. Ultimately, of course, it is still the patient's decision whether to go forward or not.

    The table of risk is measuring the risk to the patient of the selected treatment.

    With documentation that only indicates that various treatment options (up to and including surgery) were discussed, I would not consider this a decision for surgery, and would probably choose my level of risk from the presenting problem column (or perhaps diagnostic procedure(s) ordered).

    If the physician had stated, I recommend xxxx (surgery); pros and cons explained, indications and non-operative treatment options also explained. Patient will review and contact us to schedule surgery. I would be more inclined to give him credit in the table of risk for having selected the management option.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3


    I agree with what Tessa wrote but one other thing to consider would be billing based on time. My surgeons spend most of the visit counseling the patient on their treatment options. When counseling encompasses >50% of the visit, you can bill based on time.

    Just a thought. Then the table of risk doesn't matter

    Lisi, CPC

  4. #4


    Thanks! It does help and I agree.

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