Appendix A 366 ||||||||||| APPENDIXES CPT copyright 2015 American Medical Association. All rights reserved. Table of Risk, continued Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Options ­Management Selected Low EETwo or more self-limited or minor problems EEOne stable chronic illness, eg, well-controlled hypertension or non–insulin-dependent diabetes, cataract, BPH EEAcute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain EEPhysiologic tests not under stress, eg, pulmonary func- tion tests EENon-cardiovascular imaging studies with contrast, eg, barium enema EESuperficial needle biopsies EEClinical laboratory tests requiring arterial puncture EESkin biopsies EEOver-the-counter drugs EEMinor surgery with no identified risk factors EEPhysical therapy EEOccupational therapy EEIV fluids without additives Moderate EEOne or more chronic ill- nesses with mild exacerbation, progression, or side effects of treatment EETwo or more stable chronic illnesses EEUndiagnosed new problem with uncertain prognosis, eg, lump in breast EEAcute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis EEAcute complicated injury, eg, head injury with brief loss of consciousness EEPhysiologic tests under stress, eg, cardiac stress test, fetal contraction stress test EEDiagnostic endoscopies with no identified risk factors EEDeep needle or incisional biopsy EECardiovascular imaging studies with contrast and no identified risk factors, eg, arteriogram, cardiac catheterization EEObtain fluid from body cavity, eg, lumbar puncture, thoracentesis, culdocentesis EEMinor surgery with iden- tified risk factors EEElective major surgery (open, percutaneous, or endoscopic) with no identified risk factors EEPrescription drug management EETherapeutic nuclear medicine EEIV fluids with additives EEClosed treatment of fracture or dislocation without manipulation High EEOne or more chronic illnesses with severe exacerbation, progression, or side effects of treatment EEAcute or chronic illnesses or injuries that pose a threat to life or bodily function, eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with poten- tial threat to self or others, peritonitis, acute renal failure EEAn abrupt change in neurologic status, eg, seizure, TIA, weak- ness, or sensory loss EECardiovascular imaging studies with contrast with identified risk factors EECardiac electrophysiological tests EEDiagnostic endoscopies with identified risk factors EEDiscography EEElective major surgery (open, percutaneous, or endoscopic) with identi- fied risk factors EEEmergency major sur- gery (open, percutane- ous, or endoscopic) EEParenteral controlled substances EEDrug therapy requiring intensive monitoring for toxicity EEDecision not to resus- citate or to de-escalate care because of poor prognosis
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