Neurosurgery Coding Alert

Question: Do inherent risks, such as perforation, make all surgeries “high risk” in terms of medical decision making (MDM)?

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Answer: Unfortunately, there isn’t a straightforward answer. Every surgical procedure carries some element of risk. However, a relatively simple procedure for an otherwise healthy adult carries a different level of risk than the level of risk for an older patient with multiple comorbidities. Furthermore, CPT^® coding does not define ordinary surgical risks, (such as perforation) as high or low risk for patients.

Consider this verbiage found in the E/M 2021 Errata and Technical corrections:

“The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based on the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities).”

In other words, the physician or qualified healthcare professional (QHP) who evaluates the patient is the one who is qualified to judge the specific patient factors that make a procedure “high risk” for that patient. For that reason, it’s best that the documentation clearly identifies the level of risk.