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MDM Table of Risk question

  1. Unhappy MDM Table of Risk question
    Medical Coding Books
    My team and I of Medical Record Auditors have a question about how to give a provider credit for MDM. He wants a patient to have a surgery but she wanted to wait and decide at a later time. Do we give the provider credit for the procedure under the Table of Risk Mangament Options even though it has not been ordered?

  2. #2
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    my vote is no
    my question is - what procedure would you give credit for if you did give credit?
    it's just a "plan" for surgery - either now or in the future, no procedure. (in my opinion)

    hopefully others will chime in too
    Donna, CPC, CPC-H

  3. Default
    So on the table of risk....management options (such as Minor surgery with identified risk factors) mean that a procedure has been ordered or planned to give the doctor credit for it? It should say treatments then...instead of management options shouldn't it?

    I was thinking that management options were options the doctor discussed with the patient regarding treatment during the office visit...??

  4. #4
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    wow...i'm really off today - misread this post also! (thought you wanted to put this under the "dx procedure ordered" area of the Risk Table.... sorry for my confusion

    anyway - I still say no - I believe the credit for that will come when/with the appointment they have when the patient decides to have surgery. The risks will be gone over at that time, surgery will be scheduled, etc... then, I'd give credit. But as far as the doctor suggesting it, and the patient saying "I'll wait",...then no - I wouldn't give credit under the managemente options on the table of risk.

    (gosh, I hope read it right this time!) LOL... I'm going home...long long day..
    Donna, CPC, CPC-H

  5. #5
    Location
    north seattle wa
    Posts
    103
    Default
    I would say he would get credit at this visit. The table is for Risk of complications and/or morbidity or mortality. Whether or not the patient decides to take the doctors advice or not, the risk involved with the patients condition and the medical decision making process the doctor used to arrive at his assessment that the patient needed surgery hasn't changed. It's the same cognitive work involved and that is what the MDM is trying to capture.

  6. #6
    Default
    The table of risk identifies the risk "until the next patient encounter...."

    so, if the next patient encounter isn't for surgery.... I wouldn't give them that risk...

  7. Question
    So what if the pt decides to have the surgery after a day of thinking about it? Won't the pt just call the doctor and let him know that they want the surgery? It seems like the risk wouldv'e been talked about in the office visit...thus her wanting to "think" about the surgery. (I mean I wouldn't want to think about something without know the whole picture regarding risks, etc.) Wouldn't the doctor order the surgery based on her call saying yes to the surgery? Or would the pt have to come in for another office visit just to let the doctor know they now agree to the surgery...? I'm probably making this way to difficult, sorry. I tend to overanalyze things sometimes.

  8. #8
    Default
    the E/M that resulted in the decision for surgery ... I would give that risk ... I was thinking more along the lines, patient chose in 6 months to have the surgery, obviously she'd need to be seen again, and I'd give that second E/M the risk.

  9. #9
    Location
    Kansas City, MO
    Posts
    92
    Default
    I would give the physician credit for the recommended surgery. If you waited on the patients decision the management options would never be counted. Say for example you were wanting to use the "prescription drug management" because the physician was starting the patient on a new drug....would you then wait till the next visit to make sure the patient actually filled the prescription and took the medicine as directed??

    Just my way of thinking, I could be wrong.

  10. #10
    Location
    Milwaukee WI
    Posts
    4,466
    Default I'd give credit for the thought process
    I would give credit in the MDM Risk Table if the physician is recommending surgery as a management option, whether or not the patient agrees. The entire table of risk is an attempt to quantify the physician's thought process in making decisions on patient treatment. If surgery is actually recommended, whether the patient agrees or not, the physician had to have considered the plusses & minuses of that treatment option.

    Just my thinking out loud ...

    F Tessa Bartels, CPC, CPC-E/M

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