Otolaryngology Coding Alert

Question: When using the table of risk, what determines the identified risk factors or no identified risk factors of complications for endoscopic or major surgery? Does the physician have to mention the risk factors to get that management option in an audit?

Ohio Subscriber

Answer: Yes, the otolaryngologist must document the specific risk factors in the patient's unique medical history that might affect the outcome and put her at greater risk than a patient without additional risk factors. All patients undergoing an endoscopy or major surgery face a certain amount of risk. Therefore, the procedure's ordering is always the same.

To use the higher level of risk for identified risk factors, the patient must have an underlying health condition or comorbidity that makes the diagnostic procedure or surgery's positive outcome more questionable and therefore increases the procedure's risk. Examples of identified risk factors you might see include asthma, diabetes, hypertension, smoking, blood-thinner use and revision surgery.