OCT 13, 2023
Discussion of Surgery and Level of Risk
If a surgeon discusses a surgical procedure with a patient, but the patient decides not to proceed, can this still be classified as an E/M level 4? Would this also apply to optometrists who document surgical risks and benefits and refer patients for evaluation by an ophthalmologist?
Answer:
First, it's important to note that only a surgeon can make the decision for surgery; an optometrist can refer a patient to a surgeon for consultation.
If a decision is made by the ophthalmologist to recommend medically necessary surgery but the patient chooses not to proceed, it can contribute to a moderate level of risk for the medical decision-making when well documented. To qualify for an overall level 4 E/M, at least one other component (problem or data) must also meet the moderate-level criteria.