Risk of Patient Management

Question:

Is a decision to NOT perform an injection with risk factors discussed “moderate” risk?

Ex: The patient has done 6 weeks of physical therapy for their spinal stenosis, which has provided some relief, but he is not at the treatment goal. We discussed performing a lumbar epidural steroid injection with the risks of the procedure, including bleeding, infection, and nerve damage. The patient is a diabetic, and we discussed the risks of the corticosteroid injection elevating blood glucose levels. After this discussion, he elected to continue PT and avoid injection at this time.

Answer:

Yes, a decision for treatment, in this case, an epidural injection, is a medical decision made by the physician. Even if the patient defers this recommendation, it still constitutes a medical decision and one with documented patient and procedure risks.

Per CPT Guidelines:

For the purposes of MDM, the level of risk is based upon the consequences of the problem (s) addressed at the encounter when appropriately treated. Risk also includes MDM for initiating further testing, treatment, and/or hospitalization.

1) The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified healthcare professional during the reported encounter.

2) Includes the possible management options selected and those considered but not selected after sharing MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care.

*This response is based on the best information available as of 12/5/24.