Medicare patient presents for consult with general surgeon – History of colon polyps and need for screening colonoscopy
Problems – 1 Hx of colon polyps
Data – 0
Risk – Decision to proceed with screening colonoscopy

PMH includes – Prostate hypertrophy, HTN, and type 2 diabetes, but none of these conditions is specifically identified as a risk factor for surgery, just listed in the PMH.

Is this a minor surgery (per CMS definition global period 0 days 45378), a minor surgery with identified risk factors since the additional conditions are listed in the PMH, or a major surgery with/without identified risk factors.

Is there any reference where I could find direction on how to determine minor versus major surgery for MDM?

In order to be considered identified risk factors does the physician have to document a possible negative impact on the proposed surgical procedure or is it enough to simply list the conditions in the medical history?

Thank you in advance. Any input is greatly appreciated.

Angela