DecisionHealth, DecisionHealth - 2023 Issue 5 (May)
Q&A: Count MDM risk level based on viable treatment options discussed at encounter
Question: When selecting the level of risk to code based on medical decision making (MDM), the 2023 E/M guidelines state that you can count the risk of treatment options that were discussed but ultimately not chosen. We are wondering how much discussion must be documented in order to count toward risk? For example, our providers will list the treatment options and then document what was recommended and decided:
“Treatment Options: Observation versus activity modification and rest versus NSAIDS versus cortisone injection versus Hyalgan injection versus PRP Injection versus surgical intervention.
Discussion: I discussed with the patient in detail that she would need to have a BMI under 40.0 prior to a total knee replacement in the future.
Recommendation: I recommend the patient treat her symptoms conservatively with rest, ice/heat, NSAIDS, and activity modification.”
In the above note, injections and total knee replacement were mentioned as treatment options but nothing was documented about those options being discussed. Can we choose level 4 for this part of the MDM (intra-articular injection and major surgery) or can we only choose a level 3 because the only options documented as being discussed were rest, ice/heat and NSAIDS etc.?
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