Primary Care Coding Alert

Question: In the current CPT^® Elements of Medical Decision Making (MDM) table, one of the examples of moderate risk of complications is “decision regarding elective major surgery without identified patient or procedure risk factors.” What does this mean, and how does it differ from the high risk of complications example where the patient or procedure risk factors are identified?

For example, a patient is diagnosed with stenosis and radicu­lopathy. After some imaging and some conservative treatment, the doctor recommends surgery as the next step and explains this to the patient. The patient then decides against surgery or wants to put it off or get a second opinion. Does this qualify as risk? And if so, what level of risk is it?

AAPC Forum Participant

Answer: Two factors come into play when you attempt to calculate the level of risk in this scenario.

First, “the risk of complications … includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family,” according to the AMA’s most recent Office or Other Outpatient and Prolonged Services Code and Guideline Changes found at www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf .So, even though the patient refused surgery, the decision still counts as an element of risk as the element is determined by the provider’s thought process in evaluating the outcome of the decision, not by whether the provider or patient decide to act upon the decision.

Second, you would determine the level of risk based on whether the documentation has identified patient or procedure risk factors for the surgery. If your provider has thoroughly explained to the patient the risks inherent in the procedure and any medical problems the patient themselves have that could influence the outcome of the procedure, and all these things have been documented, then you could make a case for a high-risk MDM level.