Wiki table of risk

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solocoder

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I know this is a repeat question, but I'd sure like to get some thoughts.


Note says: Surgical procedure for resection of plantar calcaneal spur is explained to her in detail.* Surgery is not recommended as of yet.

The doctor thinks this should be considered "moderate" on the Table of Risk for the surgery discussion? I'm thinking the "not recommended" part cancels out the risk.
 
There could be other factors for the moderate - was a prescription given? Plus you have a acute complicated problem. Plus the risk was explained at the time even though the procedure wasn't completed.
 
It's tough to make a good call on this without better documentation. I would want to ask the provider why he/she feels the risk is moderate. Keep in mind the CPT definition of a moderate severity: "A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment." The provider should be able to explain their thinking and also have confidence that any other provider with a knowledge of this condition would agree with this level of risk just based on the information that was documented.
 
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