Decision for Surgery: Always a Level Five?
Question:
If the surgeon documents the decision for surgery and places the standard risk paragraph for that surgery, is this automatically a high level of risk?
Answer:
Thank you for your inquiry as this is not an uncommon question; we discuss this at length in the KZA coding courses.
There are two risk levels associated with the decision for surgery:
Moderate: Decision for Surgery without documentation of procedure risks and patient specific risks for that surgery.
High Risk: Decision for Surgery with documentation of procedure risks and patient specific risks for that surgery.
Remember, this Risk Element is only of the three Medical Decision Making (MDM) Elements. To meet a level four or level five encounter, two of the three MDM Elements either need to be at or meet the associated E&M level.
The number and complexity of problems addressed.
The amount and/or complexity of data to be reviewed and analyzed.
The risk of complications and/or morbidity or mortality of patient management.
*This response is based on the best information available as of 7/03/25.
