E/M Table of Risk

March 29th, 2017 - Wyn Staheli
Categories:   Evaluation & Management (E/M)   CPT® Coding  
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The final sub-component of Medical Decision Making is the Risk of Significant Complications, Morbidity and/or Mortality. The following is the official Evaluation and Management Table of Risk. The level is selected by choosing one element from three criteria (Presenting Problem, Diagnostic Procedures Ordered, and Management Options), with the highest level selected determining the final score.

Level of Risk

Presenting  Problem

Diagnostic Procedure(s) Ordered

Management Options

Minimal

  • One self-limited or minor problem (cold, insect bite)
  • Lab tests req. venipuncture
  • Chest x-rays
  • EKG/EEG
  • Urinalysis
  • Ultrasound, e.g., Echocardiography
  • KOH prep
  •  Rest
  •  Gargles
  •  Elastic bandages
  •  Superficial dressings
Low
  • Two or more self-limited or minor problems
  • One stable chronic illness, e.g., well controlled hypertension, non-insulin dependent diabetes, cataract, BPH
  • Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain
  • Physiologic tests not under stress, e.g., pulmonary function tests
  • Non-cardiovascular imaging studies with contrast, e.g., barium enema
  • Superficial needle biopsies
  • Clinical laboratory tests requiring arterial puncture
  • Skin biopsies
  • Over-the-counter drugs
  • Minor surgery with no identified risk factors
  • Physical therapy
  • Occupational therapy
  • IV fluids without additives
Moderate
  • One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
  • Two or more stable chronic illnesses
  • Undiagnosed new problem with uncertain prognosis, e.g., lump in breast
  • Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis
  • Acute complicated injury, e.g., head injury with brief loss of consciousness
  • Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test
  • Diagnostic endoscopies with no identified risk factors
  • Deep needle or incisional biopsy
  • Cardiovascular imaging studies with contrast and no identified risk factors, e.g., arteriogram, cardiac catheterization
  • Obtain fluid from body cavity, eg lumbar puncture, thoracentesis, culdocentesis
  • Minor surgery with identified risk factors
  • Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors
  • Prescription drug management
  • Therapeutic nuclear medicine
  • IV fluids with additives
  • Closed treatment of fracture or dislocation without manipulation
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 MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acuterenal 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

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