# Minor v. Major surgery definition



## traci071@yahoo.com (Feb 5, 2021)

Hello All,

Wondering if anyone has information regarding a broader definition of minor v. major surgery (other than the global period identifier).   Specifically, as it pertains to the 2021 E/M guidelines, where level 4 has decision for minor surgery v. level 5 having decision for major surgery - in a situation where the procedure being scheduled is the only point which can (possibly) up it to a level 5.   The E/M is a level 4 on the diagnoses element, it can reach the threshold for a 5 on data, and the procedure scheduled is a 93458.   

Thank you


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## SolarShiva18 (Feb 8, 2021)

Level 4 risk has both minor surgery with identified patient or procedure risk factors and major surgery *without* identified patient or procedure risk factors in it, level 5 major surgery is *with* identified patient or procedure risk factors. If the only thing that would up it to level 5 is risk it wouldn't be a level 5 as you need 2 of the 3 MDM categories to get the level so would also need number/complexity of problems or complexity of data to give a level 5.


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## Farrellandrews (May 6, 2021)

Is bunionectomy considered "Minor surgery" or "Major surgery"?  It is the difference between a 99213 and a 99214 if there is "no risk".  Or could anyone point me to a reference?  Thanks.


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## VSMichael (May 6, 2021)

This Q&A was taken from the Coding Intel website: https://codingintel.com/changes-to-history-and-exam-element-requirements-for-em-services/

*"Major or minor procedure?

Question:* I have a question about how to determine if a procedure is a major or minor procedure when assessing risk in the new E/M guidelines for office visits. I heard from a colleague that the AMA is saying it is the surgeon’s judgment and not the global days that determines if the procedure is major or minor. Is that right?

*Answer*: Yes. Solely for the purpose of determining the level of risk using the new office visit guidelines, the AMA said at a symposium not to use global days to determine if a procedure is a minor procedure or a major procedure. Using global days would mean heart catheter, endoscopy, and some spinal procedures would be minor procedures.

The new guidelines now read “decision regarding minor surgery with identified patient or procedure risk factors,” “decision regarding elective major surgery without patient or procedure risk factors,” and “decision regarding elective major surgery with identified patient or procedure risk factors.” It is recommended that the physician document risk factors that are inherent to the procedure (bleeding, puncturing the lung, paralysis) and risk factors related to co-morbidities and conditions of the patient."

I hope this helped!


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## jkyles@decisionhealth.com (May 10, 2021)

Just chiming in to add that the extensive technical correction to the new E/M guidelines posted March 9 included more detail on major vs. minor surgery https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf


> Surgery (minor or major, elective, emergency, procedure or patient risk):
> Surgery–Minor or Major:The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.”These terms are not defined by a surgical package classification.
> Surgery–Elective or Emergency: Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing isrelated to the patient’s condition. An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.
> Surgery–Risk Factors, Patient or Procedure:Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.


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## KoBee (May 17, 2021)

Hello, 

So if a provider documents: surgery plan for right knee arthroscopy with possible meniscus treatment, chondroplasty, loose body removal, other procedures indicated. 

Along with the *associated risks*, benefits and rationale, with the risks of surgery including but not being limited to residual pain/CRPS, bleeding, infection, scarring/keloid, stiffness or instability, injury to neighboring structures including bone (fracture), cartilage, muscle, tendon, ligament, blood vessel and nerve with associated numbness/weakness, need for additional procedures/revision, post-traumatic OA, extremity dysfunction, allergic reaction to anesthesia/medications, DVT/PE, pneumonia, MI, CVA, coma, death, other anesthesia risks, infectious disease transmission, including COVID-19, and their associated risks, up to and including death. I specifically discussed that the goal of surgery is the improvement of mechanical symptoms, not pain relief.  I also discussed that arthroscopy will not change any existing OA.

would this considered enough to count as HIGH under risk of complications? not level of service high but just for the element.


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