I am looking for clarification on whether or not a provider reviewing multiple treatment options with the patient counts as a “decision for surgery” as long as one of those options is surgery, regardless of the patient's current presentation or a definitive recommendation by the Provider.
Example:
“I discussed various treatment options including OTC meds, physical therapy or surgery. This condition may also resolve on its own 50% of time. All the patients questions were answered. Patient will take a wait and see approach. Patient will follow-up as needed.”
Example:
“I discussed various treatment options including OTC meds, physical therapy or surgery. This condition may also resolve on its own 50% of time. All the patients questions were answered. Patient will take a wait and see approach. Patient will follow-up as needed.”