Appendix A 398 | | | | | | | | | | | AP PENDIXES CPT copyright 2015 American Medical Association. All rights reserved. Table of Risk Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected Minimal One self-limited or minor problem, eg, cold, insect bite, tinea corporis Laboratory tests requiring venipuncture Chest x-rays EKG/EEG Urinalysis Ultrasound, eg, echo-cardiography KOH prep Rest Gargles Elastic bandages Superficial dressings Low Two or more self-limited or minor problems One stable chronic illness, eg, well controlled hypertension, non–insulin-dependent diabetes, cataract, BPH Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain Physiologic tests not under stress, eg, pulmonary function tests Non-cardiovascular imaging studies with contrast, eg, 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 exacer­ bation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prog­ nosis, eg, lump in breast Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis­ Acute complicated injury, eg, head injury with brief loss of consciousness Physiologic tests under stress, eg, 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, eg, arteriogram, cardiac catheterization Obtain fluid from body cavity, eg, lumbar punc- ture, thoracentesis, culdocentesis Minor surgery with identified risk factors Elective major surgery (open, percutane- ous, 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 exacer- bation, progression, or side effects of treatment Acute 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 potential threat to self or others, peritonitis, acute renal failure An abrupt change in neurological status, eg, ­ seizure, TIA, weakness, sensory loss Cardiovascular imaging studies with contrast with identified risk factor Cardiac electrophysiological tests Diagnostic endoscopies with identified risk factors Discography Elective major surgery (open, percu­ taneous, or endoscopic) with identified risk factors Emergency major surgery (open, per­ cutaneous, or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitor- ing for toxicity Decision not to resuscitate or to ­prognosis de-escalate are because of poor
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