Surgeons as Educators A Guide for Academic Development and Teaching Excellence

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Considering it is primarily an office procedure, it seems counterintuitive, that is, a
major procedure, but I didn’t make the rules.

Q2 What is a surgical risk factor?

A2 Any patient condition that increases the surgical risk of complication (i.e., obe-
sity, diabetes, blood thinners, etc.). The majority of patients have a risk factor. It is
important to explicitly state in your note what these risks are. Something like, we
discussed the risks and benefits of major penile implant surgery and specifically
described his infection rate increased from <1 up to 3% based on his diabetes
diagnosis.
Noteworthy level 5 categorizations include elective major surgery with risk fac-
tors, giving parenteral controlled substance (narcotics, etc.) or acute or chronic ill-
ness or injury that poses a threat to life or body function (MI, acute renal failure,
etc.).
After studying the risk table for a short time, you will memorize the most com-
mon things you do in your practice and automatically know how to bill. You will
quickly learn that anytime you write a script, it should be a level 4 visit (because of
course you have already completed a level 4 history and physical exam portion of
the note). Anytime you schedule surgery, it should be a level 4 or 5 visit. Take a
moment to review the difference in RVUs between levels 3, 4, and 5 visits.

Table 23.3 (continued)

Table of risk

Level of risk Presenting problem(s)

Diagnostic procedure(s)

ordered

Management

options selected

High One or more chronic

illnesses with severe

exacerbation. progression,

or side effects of treatment

Acute or chronic illnesses

or injuries that pose a

threat to life or bodily

function, e.g., multiple

trauma, acute Ml,

pulmonary embolus,

severe respiratory distress,

progressive severe

rheumatoid arthritis,

psychiatric illness with

potential threat to self or

others, peritonitis, acute

renal failure

An abrupt change in

neurologic status, e.g.,

seizure, TIA, weakness,

sensory loss

Cardiovascular imaging

studies with contrast with

identified risk factors

Cardiac electrophysiological

tests

Diagnostic endoscopies with

identified risk factors

Discography

Elective major

surgery (open,

percutaneous, or

endoscopic) with

identified risk

factors

Emergency major

surgery (open,

percutaneous, or

endoscopic)

Parenteral

controlled

substances

Drug therapy

requiring intensive

monitoring for

toxicity

Decision not to

resuscitate or to

de-escalate care

because of poor

prognosis

T.S. Köhler