![]() It includes a brief video summary and downloadable quick reference sheet “Credit for Tests in Data Element”. Data Elementsįor additional information about data elements, read The second element of MDM in 2021: data. Treating a non-displaced fracture without manipulation has fewer procedure-inherent risks than taking a patient to the operating room to reduce an open fracture. ![]() Skin procedures that can be done in the office with lidocaine would be more likely to be minor procedures than procedures done in the operating room under general anesthesia. Where the procedure is done and the type of anesthesia may also factor into this determination. The new guidelines now read “decision regarding minor surgery with identified patient or procedure risk factors,” “decision regarding major surgery with patient or procedure risk factors,” and “decision regarding minor surgery with patient or procedure risk factors.” I recommend that the physician document risk factors that are inherent to the procedure (bleeding, puncturing the lung, paralysis) and risk factors related to co-morbidities and conditions of the patient. Using global days would mean heart catheter, endoscopy, and some spinal procedures would be minor procedures! This language is confirmed in writing in the 2022 CPT book. Solely for the purpose of determining the level of risk using the new office visit guidelines, the AMA said at a symposium not to use global days to determine if a procedure is a minor procedure or a major procedure. I heard from a colleague that the AMA is saying it is the surgeon’s judgment and not the global days that determines if the procedure is major or minor. Question: I have a question about how to determine if a procedure is a major or minor procedure when assessing risk in the new E/M guidelines for office visits.
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