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MDM - Selection of Risk

Risk

The probability and/or consequences of an event. 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. 

Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. 

Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). 

For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. 

The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.

Morbidity

A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment. 

Social determinants of health 

Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.

Surgery (minor or major, elective, emergency, procedure or patient risk):  

Surgery–Minor or Major

The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification. 

Surgery–Elective or Emergency

Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing is related to the patient’s condition. 

An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization.

Both elective and emergent procedures may be minor or major procedures.

Surgery–Risk Factors, Patient or Procedure

Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.

Drug therapy requiring intensive monitoring for toxicity

A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. 

The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy.

The monitoring should be that which is generally accepted practice for the agent but may be patient-specific in some cases. 

Intensive monitoring may be long-term or short-term. Long-term intensive monitoring is not performed less than quarterly. 

The monitoring may be performed with a laboratory test, a physiologic test, or imaging. Monitoring by history or examination does not qualify. 

The monitoring affects the level of MDM in an encounter in which it is considered in the management of the patient. 

Examples may include monitoring for cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis. 

Examples of monitoring that do not qualify include monitoring glucose levels during insulin therapy, as the primary reason is the therapeutic effect (even if unless severe hypoglycemia is a current, significant concern); or annual electrolytes and renal function for a patient on a diuretic, as the frequency does not meet the threshold. 

Return to E/M Guidelines for Office/Outpatient 2021

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