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
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