Wiki E/M MDM - Decision for Surgery

[suemt]

I am interested in feedback on the decision for surgery when coding E/M MDM.

If the provider makes a decision for surgery in visit #1, but the patient does not also decide, does the decision count (meaning, do you get the MODERATE points for decision for surgery)?

And what happens when the patient comes back a couple months later and is then ready for the surgery? The provider does do an assessment, but essentially the decision has already been made and absent any changes in the patient's medical condition, the surgery that was already decided a couple months ago is scheduled. So the question is, does the provider again get to count the decision for surgery towards a MOD MDM?

Thanks in advance for your responses!

Sue

 

[MarcusM]

If conservative treatment options have been tried, documented and did not provide relief as also documented, then if the surgical options have been discussed with the patient, and there is objective evidence for surgery, then that would be the surgical decision. Since the patient opted to think about it, the second visit would be more in line with whatever counseling is needed for surgery and rehab post- surgery. There most likely would not be enough for another decision for surgery unless the conditions worsened substantially.

 

[OCD_coder]

I agree a little bit with Marcus here. Visit #1: When a provider presents all options to the patient and surgery is one of those options, that is the decision for surgery moment and now the patient is basically in a global bubble and the next service is considered preop if all the patient does is state "I choose surgery". This encounter includes re-reviewing the surgery and risks and answering all patient questions is part of preop work. E&M's are based on the providers medical decision making, not the patients. We can't take into consideration the patient's decision because we would be penalizing the provider when a patient refuses treatment such as an admit when they are very ill.

If the patient determines they want to go the conservative route for treatment at the second visit, then that global bubble is turned off and the visit can be reported as long as the treatment plan they go with is documented.

If the patient comes back a few months later and says "I am ready for surgery now", I would really have to take a look at the documentation, but if there is no additional workup or maybe a different surgery was determined from the original I would hesitate in calling this "the decision for surgery." Re-assessing the patient is part of preop work.

This is can be a very confusing scenario when so many different ways can be considered, I try to look the medical necessity in determining when the "decision" occurred. If the patient could have made a phone call to notify the surgeon what their decision was, but the surgeon is making the patient come in to tell them thinking they can bill an extra E&M would not be appropriate.