Determining the Level of Risk 89 Determining the Level of Risk Determining the Level of Risk This article examines how the level of risk of complications and/or morbidity or mortality of patient management is determined as an element of medical decision-making (MDM) for office and other out- patient evaluation and management (E/M) services provided in 2021. Note that the changes discussed in this article affect only office E/M services reported with codes 99202–99205 and 99211–99215. As a reminder, in 2021, code selection for office E/M services may be determined either by MDM alone or based on the physician’s or other qualified health care professional’s (QHP’s) total time devoted to care of a single patient on the date of the encounter. Codes differentiate new and established patients, but the same level of MDM is required for both new and established patient visits (ie, straightforward MDM supports level 2 office visit code 99202 [new patient] or 99212 [established patient]). MDM may be straightforward, low, moderate, or high. MDM is determined by the highest levels in 2 of the following 3 elements: 1. The number and complexity of problem(s) that are addressed during the encounter 2. The amount and/or complexity of data to be reviewed and analyzed 3. The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), and/or treatment(s) Risk In terms of MDM, risk is the probability and/or consequences of an event. The level of risk is based on consequences of the problem(s) addressed at the encounter when appropriately treated. Definitions of risk are based on the usual behavior and thought processes of a physician or other QHP in the same specialty. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. For example, a decision to hospitalize a patient and a decision to not hospitalize but monitor closely as an outpatient are each examples of high risk of morbidity. Ped Office-based EM Coding booklet interior.indd 89 Ped Office-based EM Coding booklet interior.indd 89 9/14/20 12:02 PM 9/14/20 12:02 PM
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