General Surgery Coding Alert

Question: The surgeon performed a pre-op visit before hernia surgery, and the patient has diabetes. How do we factor that into the table of risk for medical decision-making to choose the appropriate E/M code?

Louisiana Subscriber

Answer: The rule of thumb is that for surgical patients with no risk factors, or minor-surgery patients with controlled risk factor(s) that might make the surgery more dangerous, you should assign moderate risk.

In this case, if the surgeon mentioned the patient’s diabetes because it is uncontrolled or otherwise severe and increases the patient’s risk of death or injury from the surgery, it might warrant high-risk medical decision-making (MDM). The surgeon would then need to document this part of the decision making and the determination to move forward with the surgery anyway.

That’s not all: Remember that the table of risk is just one factor to consider when choosing the level of MDM complexity. You must also consider the following other two components, which typically lower the level of MDM:

• Diagnostic or management options component. A single established problem that is under control puts diagnostic options at the minimal level. If the surgeon is clearing more than one problem condition, you might edge up to a limited level or possibly moderate (because many additional conditions requiring clearance). If the management option is a particular surgery, the level is still minimal. If the problem is not under control, the chances are that surgeon will opt against surgery at this time.
• Data review component. If your surgeon reviews lab and radiological tests as part of the surgery clearance, you would be at a limited level for data review. If the surgeon reviews only lab tests, then it would decrease to minimal data.

Consider: Despite moderate risk from the table of risk, you might have only minimal diagnostic/management options and limited complexity of data reviewed. You must meet or exceed two of the three to raise the level of MDM.

If you document moderate risk, you can only get to moderate complexity of MDM with a moderate level in either the data reviewed or diagnostic/management options component. So, even if your physician performs a comprehensive examination or history for this established patient, medical decision making will be the final determiner of the level of service — usually a 99213 (Office or other outpatient visit for the evaluation and management of an established patient …), though sometimes you may document a 99214 (Office or other outpatient visit for the evaluation and management of an established patient…).