# Dx endoscopy with risk factor



## kbartrom (Apr 8, 2010)

Does anyone have a policy or info regarding when they consider an endoscopy to be "with risk factor" on the risk table for medical decision making?

Thank you!


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## mhcpc (Apr 9, 2010)

I count if the patient is on a blood thinner and the physician is having him hold it for the procedure.


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## j.berkshire (Apr 9, 2010)

This would be a physician's judgement, but might nclude patients with cardiac or pulmonary disease.  There is inherent risk in all procedures, and the guidelines state that risk is based on the risk during and immediately following any procedures or treatment.   The risk table defines high risk as a patient undergoing diagnostic endoscopy with IDENTIFIED risk factors.  The risk is particular to each situation and should be defined by the physician.


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## allison_w_99 (Sep 23, 2015)

So if the patient is being seen at the hospital, and the patient agrees to proceed with the procedure and physician documents during the encounter that "The patient was informed of pertinent risk factors including but not limited to bleeding, perforation, medication reaction," etc.. the patient could be classified as high risk in terms of MDM?  Would these be considered inherent risks or can they be counted towards the overall level of the visit since the physician has identified that he discussed them w/the patient?


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