I work for Orthopedic Specialists and I have a Dr that always discusses surgery as an option along with conservative treatment. I am confused as to when I should give him points in the MDM for surgery. Does he get points just for discussing surgery or does it need to be the treatment plan that was decided? Here is an example from a patient with a rotator cuff tear:
Imaging findings were reviewed along with relevant treatment options, both nonoperative and operative with their respective pros and cons. We reviewed the rx options and indications for surgery: L Shoulder scope/ SAD/ bicpes tenodesis and poss RCR; Nonoperative mgmt was also explained; he will review his options and contact us prn for further rx;
Most of the audit forms that I have state Management options selected not discussed. What do you guys think? Does anyone have a source you can point me to for this when talking to the Dr's and management about this?
Thanks for your help!
Heather
Imaging findings were reviewed along with relevant treatment options, both nonoperative and operative with their respective pros and cons. We reviewed the rx options and indications for surgery: L Shoulder scope/ SAD/ bicpes tenodesis and poss RCR; Nonoperative mgmt was also explained; he will review his options and contact us prn for further rx;
Most of the audit forms that I have state Management options selected not discussed. What do you guys think? Does anyone have a source you can point me to for this when talking to the Dr's and management about this?
Thanks for your help!
Heather