Wiki level 4 E&M risk column

[NEOSM507]

Good morning,

I need some clarification with the language used in the risk column for a level 4 E&M. Specifically when they refer to the "with/without identified patient or procedure risk factors". Why would a minor surgery discussion count with but a major surgery discussion count without? Every surgery (minor or major) has risks that are discussed.

Decision regarding minor surgery with identified
patient or procedure risk factors

Decision regarding elective major surgery without
identified patient or procedure risk factors

Thank you

 

[thomas7331]

A minor surgery without identified risk factors would be consider low risk for MDM purposes, whereas if there are additional specific risks to the patient of a minor surgery, then it would be considered moderate risk. A major surgery by its very nature involves a higher level of risk than a minor procedure, so a major procedure warrants moderate risk in the MDM without additional risk factor being identified - if a major surgery involves additional risks, then it would be classified under high risk in the MDM.

I'd just add that although the guidelines don't explicitly say this, most auditors in my experience would only count toward the MDM the identified risks MDM that are specific to a given patient due to their particular conditions and not the risks that accompany all procedures and which are given as a generic disclaimer to every patient that undergoes a surgery.