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Level of Risk in the Risk of Complications and/or Morbidity or Mortality Chart

Debra Posted Thu 16th of July, 2015 08:48:12 AM

Hi

Before I ask my question~I do understand that my selection of the E/M also has other elements, this is not my only thing I am looking at.

My example for today - Patient comes in with shoulder injury from January. This is the first time he is seeing an Orthopedic (7 months after injury).

The patient's description - At time of injury he had difficulty raising his arm over his head. Now he only has pain with certain movements. Patient does have full strength.

This patient did see his PCP and was previously sent to PT.

Now I am getting in to my specific question...

He was referred to Orthopedics because he still had some pain. He had an MRI and it showed a Labral Tear.

The doctor is suggesting surgery.

The patient does not want surgery.

The section of the Audit Tool under medical decision making... Level of Risk

I go back and forth between Acute uncomplicated illness or injury (WHICH IS LOW RISK) AND Acute Complicated illness (WHICH WOULD BE MODERATE)

The doctor suggests surgery, WHICH IS MODERATE. However, the patient is opting out of surgery.

Can you give me advise on the above concerns with selecting the correct "Level of Risk" on the Audit Tool in the medical decision making section.

Thank you!

SuperCoder Answered Fri 17th of July, 2015 03:15:56 AM

Well, you are in right direction. The condition of the patient will be moderate risk. It is not depend on the patient's verdict, it is based on the condition of the patient. You can take it moderate as one or more chronic illnesses with mild exacerbation, progression, or side effects of treatment. Hope it helps!

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