Risk

 The third part of the overall Medical decision The third part of the overall overall Medical Medical decision decision Making 

 The Risk Table is an official part of CMS Documentation Guidelines 

 Is scored independently 

 Along with Management Options and Amount and  Complexity of Data 

 Highest level of risk in any category determines the overall risk score

Nature of Presenting Problem

 99281 Usually, the presenting problems are self limited or minor 

 99282 Usually, the presenting problem(s) are of problem(s) are of low to moderate to moderate  severity 

 99283 Usually, the presenting problem(s) are of problem(s) are of moderate severity moderate severity.

 99284 Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not by the physician physician but do not pose an immediate significant threat to life or physiologic function. 

 99285 Usually, the presenting problem(s) are of high severity and pose an immediate 18 are of high severity and pose an immediate immediate significant threat to life of physiologic function.

Guidelines

Any specifically identifiable procedure (ie, identified with a specific CPT code) performed on or subsequent to the date of initial or subsequent E/M services should be reported separately.

The actual performance and/or interpretation of diagnostic test/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT® codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code with modifier 26 appended.

The physician or other health care professional may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant separately identifiable E/M service above and beyond other services provided or beyond the usual preservice and postservice care associated with the procedure that was performed. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date. 

 Nature of Presenting Problem: A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter. The E/M codes recognize five types of presenting problems that are defined as follows: 

Minimal - A problem that may not require the presence of the physician or other qualified health care professional, but service is provided under the physician’s or other qualified health care professional’s supervision.

Self-limited or Minor - A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance. 

Low severity - A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected. 

Moderate severity - A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.

High severity - A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.