Wiki Help determining risk level

[Amber Blankenship]

Based off 2021 guidelines, if a provider discusses minor surgery with risk, with a patient but says that HE would like the patient to do PT first, (the patient did not make that decision) would you consider this risk factor to be low for the physical therapy recommendation or moderate for the discussion of minor surgery with risk.

I have always thought that if there were 2 choices to choose from and the provider made the decision to forego the surgery, not the patient, for the PT, the risk would be low for the PT recommendation. Is that correct? Or do you give the provider the moderate risk just for the discussion of surgery that was not planned.

Thanks

 

[rachaelwilleford]

I would say it depends on if the provider explained the reasoning for not going with the surgery.

 

[csperoni]

I agree. It depends on how it is documented. It is about the DECISION REGARDING surgery, not necessarily the decision to have surgery. If it just says "PT first, consider surgery later", then no, I would not credit surgery decision. If it states "Typical treatment for this would be arthroscopy. However patient has significant comorbidities including COPD and uncontrolled DM II putting him at very high risk for any procedure with anesthesia. Recommending PT 3x wk for 10 weeks with re-evaluation following." In example 2, the physician clearly considered surgery, but due to patient specific risks, is not recommending surgery.
From the AMA 2021 outpatient guidelines:
The risk of complications and/or morbidity 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 MDM 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.

 

[jeskla]

How would you count a discussion of major surgery without patient specific risk factors but the patient wants to discuss it with their spouse first and call with the decision?

 

[amyjph]

How would you count a discussion of major surgery without patient specific risk factors but the patient wants to discuss it with their spouse first and call with the decision?

It would probably still be moderate risk.
The fact that they want to discuss with family doesn't really impact it, with exceptions. Some exceptions might be social determinants of health. It is the risk to the patient (not just normal risks for all which are associated with surgery). Some exceptions might be social determinants of health. Again, it depends on the documentation by the provider.

https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management-em-revisions-faqs

"Risk for any procedure depends on the specific patient-risk factors and circumstances as they are assessed by the physician or other QHP."
"As a result, the physician's documentation of his or her level-of-risk assessment based on the specific patient's risk factors is the determining component in how the MDM level of risk for the specific patient will be calculated."

 

[luvbuix]

it's not about the pt here- it's about the MD's level of risk. you always should follow the highest level of risk according to the treatment plan set forth by the MD. it doesn't matter what the pt decides. keep in mind though that the treatment plan has to be DEFINITIVE. he can't give several choices based on the outcomes of tests- the decision should be made that day.