Example chart -How to determine the level of risk complication -

Risk of Significant Complications, Morbidity, and/or Mortality

The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the following categories:

** Presenting problem(s);

** Diagnostic procedure(s); and

** Possible management options.

The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between  the present encounter and the next encounter.


The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk. The level of risk of significant complications, morbidity, and/or mortality can be:

** Minimal;

** Low;

** Moderate; or

** High.


Some important points that should be kept in mind when documenting level of risk are:

** Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented;

** If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter, the type of procedure should be documented;

** If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented; and

** The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied.
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The table on the next page may be used to assist in determining whether the level of risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk.

DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING

The levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity, and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

the number of possible diagnoses and/or the number of management options that must be considered;

the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and

the risk of significant complications, morbidity, and/or mortality, as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.