Wiki Inpatient Surgeries-Patient Declines

[jordansmom2000]

Provider feels patient needs surgery gives the patient all the reasons why they feel the patient needs surgery and the patient declines the surgery. Would you give them Surgery in the risk table even though you know the surgery is not going to take place or do you look at it like that is the providers medical decision making and the patient has declined? I am referencing for inpatient so it is under the 2020 guidelines since the 2021 guidelines spell out decision very well.

 

[shayna5184]

For 2021 guidelines, it would count in the risk since the surgery wasn’t performed. If the surgery was done then the risk would count with the surgery and not in the E/m. Hope I understood your question correctly and this helps.