Wiki E/M Leveling a visit when Treatment options are discussed

Create Wiki
A

amwittler

Networker
Messages
41
Location
Laharpe, IL
Best answers
0
If a provider sees a pt with an incarcerated incisional hernia and gives them the option to continue to observe OR surgery (surgery was discussed at the visit) how is the level of the visit determined. I feel like this is confusing because if options are given then I feel like the level is going to be effected by the choice the pt makes. I know that if the provider says they need surgery and pt chooses not to then the provider still gets credit for the decision for surgery.
 

The risk of complications and/or morbidity or mortality of patient management. This includes decisions made at the encounter associated with diagnostic procedure(s) and treatment(s). This includes the possible management options selected and those considered but not selected after shared 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. Shared decision making involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options.

With that being said, I think it depends on how it is documented. What did the provider document about the discussion? What was documented about why the patient decided not to proceed with surgery? Were there any risk factors stated which would impact whether or not the patient proceeded? That kind of thing.

For example, if I am reviewing a total joint orthopedic provider's notes, and every single one where a patient has knee OA has a template at the end that says the same exact thing which mentions the fact that TKA "could" be an option, I would not count that.

However, if the note stated something like, "We discussed continuing with steroid injections every three months, or the option of proceeding with TKA. Risks and benefits were discussed. The patient is high risk due to their chronic medical conditions (diabetes, obesity, CKD) therefore, the patient and I decided against proceeding with surgery at this time." This is definitely counted.
 
Totally agree with Amy that it's all about how it's documented. I know personally as a patient, I had a doctor recently mention offhand perhaps surgery would be a consideration in the future if the problem didn't resolve within a specific timeframe. We didn't discuss anything about the specific surgery. The note says "Consider surgical options if not resolved in 2 months". That is NOT decision for surgery.
The example given above to not have surgery is a decision regarding surgery.
 
You must log in or register to reply here.
Top