Internal Medicine Coding Alert

These definitions take the mystery out of moderate vs high surgical management options.

If you audit surgery in addition to internal medicine, you could be losing E/M credit unless your emergency, elective, and risk factor vocab is rock solid.

Under the Table of Risk's Management Options Selected column, these factors can change whether the level of risk is moderate or high, affecting the encounter's type of medical decision making and potentially changing the E/M service's level.

To avoid under or over-coding the surgeon's level of risk, know the differences between:

Emergency Surgery Requires Immediate Performance

When considering emergency surgery risk, look for the following characteristics described by Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, manager of compliance education with University of Washington Physicians.

Emergency surgery is surgery that must be performed immediately. Emergency surgery is at the highest risk category, because the surgeon does not have time to do the typical clearance work. Procedures that qualify as emergency surgery include things like ruptured appendix, ruptured aneurysm, head trauma with increased intracranial pressures, gunshot wounds, active bleeding, some acute cardiac conditions, some fractures (for example pelvic ring fracture, skull fracture), and other surgeries that cannot be delayed for further work-up.

Risk Factors Apply to Individual

All surgeries carry some inherent risk. The column's designation of with and without identified risk factors refers to patient specific risks. Look for any co-morbidity the patient has that the internist is treating.

Elective surgery with no identified risk factors is any surgery that is not immediately required (meaning, it is planned for the patient's convenience) or is "cosmetic when the patient has no comorbid conditions that will increase the risk associated with the procedure, healing, and/or anesthesia," Bucknam explains. Translation: Elective surgery involves a generally healthy person who needs surgery to correct a problem (for example, cholecystectomy)," and the physician expects the person will be healthy again after the surgery.

"Elective surgery with identified risk factors is any surgery that is not immediately required when the patient DOES have comorbid conditions that will increase the risk associated with the procedure, healing and/or anesthesia," Bucknam says. "Common risk factors include diabetes (affects healing; also patient must be NPO [Nothing by mouth] before surgery and often cannot eat for a while after surgery, so blood glucose must be closely monitored), COPD (increased anesthetic risk), tachycardia with or without pacemaker (many common surgical tools (e.g., electrocautery) can trigger a tachycardic event, and if the patient has a pacemaker, it must be turned off during surgery). There are many other risk factors, including drug allergies, previous poor anesthetic outcome, morbid obesity, etc."