Is the decision to perform YAG laser peripheral iridotomy (66761) considered low or moderate in the risk category for evaluation and management (E/M) medical decision-making?

Answer:
Coding guidelines interpret minor versus major procedures by the defined global period.

American Medical Association E/M guidelines define minor versus major procedures based on the physician’s expertise and mutually understanding of the profession, akin to the use of the term “risk,” which is not a surgical package classification. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.

The Academy considers all laser would meet the definition of major surgery, based on the AMA definition. The decision to perform YAG PI would be major surgery without identified risk or a moderate level of risk in E/M medical decision-making.

Visit aao.org/em for E/M coding resources.