In the evaluation and management (E/M) framework, medical decision-making (MDM) plays a pivotal role in determining the level of service.

One of the most misunderstood elements in MDM—particularly among surgical specialties and pain management practices—is how to accurately assess risk when surgical intervention is mentioned in the documentation.

A common misconception is that listing surgery as a possible treatment option automatically elevates the risk level to moderate or high. However, the guidelines make it clear: a list of treatment options alone does not establish risk level based on the highest-risk intervention mentioned. The actual risk component in the MDM table refers to the risk associated with the decision regarding surgical intervention, not the presence of the word "surgery" in the note.

That distinction is critical. To support a higher level of risk, the documentation must reflect that the provider made a decision—either to proceed with surgery now or to seriously consider it based on the current medical presentation. This decision must be medically indicated, meaning the patient’s condition has reached a point where surgery is justified, even if the provider and patient decide to delay in favor of less invasive options.

When a note simply presents a laundry list—physical therapy, injections, lifestyle changes, and possibly surgery—it suggests that the clinical threshold for surgery has not yet been met. In these cases, the mention of surgery is more exploratory than definitive, and therefore not sufficient to justify moderate or high risk. That level of risk could be appropriate if the provider documents that surgery is the appropriate next step, but the patient elects to defer. Without that clarity, the note remains under-documented from a risk standpoint.

Auditors must asses based on documentation, not the assumed conversations that may have occurred during the visit. Providers often explain that the discussion in the room was clear about surgery being the likely next step. But unless the record captures that clarity, it doesn’t support the higher risk level. Documentation should reflect that a decision was made—that surgery is medically indicated now—even if the plan is to try less invasive treatments first or if the patient prefers to wait.

The takeaway is simple: mentioning surgery does not drive the risk.

The documented decision does.

To ensure accurate risk scoring, providers should be encouraged to clarify their intent in the record.

• Was surgery medically indicated at this visit?
• Was it recommended, but deferred due to patient preference?
• Or was it one of several long-term options under discussion without a clinical push at this time?

Each of those scenarios carries a different implication for MDM risk.

Clear, purposeful documentation isn’t just about accurate coding—it’s about protecting both the provider and the practice from compliance risk. In MDM, the risk isn’t in the list—it’s in the decision. Document it accordingly.