Wiki Consideration vs. Decision for minor surgeries.

[bdcoyne8]

We are having a discussion in our clinic as to when we can count "Decision regarding minor surgery with identified patient or procedure risk factors". I am trying to find clear guidance as to when this can be counted towards the moderate leveling.

Is it when the provider decides that the patient will have the surgery (schedules procedures, gets prior authorizations)?
Is it when the provider discusses the option for the procedure with the patient and leaves it open ended where the patient has received all of the information regarding the procedure and they will call if they want it scheduled and performed?

We have some providers who will state "we will schedule the patient for an transforaminal epidural injection" then there are some that say "we will consider scheduling the patient for a transforaminal epidural injection".

At what point is it a "decision for surgery"?

Any guidance, clarification and supporting documentation would be appreciated!

 

[csperoni]

If the provider is discussing the option and risk with the patient, you may count it, even if the patient/provider is not opting for procedure at this point.

Per AMA https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf (my emphasis added).
"The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment (s). This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment."