Coding…Decoded Series: 2021 AMA Coding Requirements
This is the third article on applying the new 2021 AMA coding documentation requirements. This column addresses the “Risk of Complications and/or Morbidity or Mortality of Patient Management.” The options are Minimal, Low, Moderate or High. The AMA guidance does not give any examples of Minimal or Low. In my opinion, Low risk includes non-recurrent yeast or bacterial vaginosis treatment or renewing contraception in a reproductive-aged person.
Moderate risk examples given are prescription drug management, decision for minor surgery with patient/procedure risk factors or major elective surgery without patient/procedure risk factors. Included in these decisions are also the decision NOT to do surgery or treatment because of significant social determinants of health. Thus, a patient may benefit from and want a hysterectomy, but because she has no one who can support her at home for the first few postoperative days, you both agree to a less effective treatment option. In this example, Moderate would be the risk classification. In my opinion, new OCP prescription, STI treatment, HRT management, and most other prescription drug therapy. There is no published definition of “minor” vs “major” surgery. The global surgical period, length of procedure or hospital admission/observation do not distinguish minor from major. The AMA says there is a “common meaning of such terms when used by trained clinicians”. While I commonly hear, “minor surgery only happens to others”, that is not a sufficient definition. I would include external and vaginal biopsies, contraceptive device placement/removal, diagnostic hysteroscopy, colposcopy and cystoscopy as examples of minor procedures. Anytime one enters the peritoneal cavity or there is a significant risk of entry causing a complication, I would consider that major. Some examples might include operative hysteroscopy, vulvectomy, diagnostic and operative laparoscopy. There will always be some borderline procedures such as LEEP or CKC that will depend on the pathology treated, patient risks and amount of tissue removed.
High risk examples given are drug therapy requiring intensive monitoring for toxicity, decision regarding elective major surgery with identified patient/procedure risk factors, decision regarding emergency major surgery, decision regarding hospitalization or decision not to resuscitate or to de-escalate care due to poor prognosis. My specific GYN examples include ruptured ectopic pregnancy, ovarian torsion, methotrexate therapy, hysterectomy for AUB in a patient with risk factors such as obesity, hypertension or diabetes, admission for observation with pelvic pain and serial abdominal exams, observation for blood transfusion and IV estrogen therapy for severe anemia with AUB and decision not to perform a hysterectomy in a patient with endometrial cancer and severe dementia. The AMA specifically excludes insulin as requiring intensive monitoring in almost every situation. The monitoring of the medication is monitoring for toxicity/complications and cannot be done by history or physical exam.
Next time we will put it all together and talk about time-based coding.