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Identifying the Components of a High-Risk Evaluation and Management Service

Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Since 2021, when the Office and Other Outpatient Evaluation and Management (E/M) services coding guidelines changed to require only scoring by time or medical decision making (MDM), coders, providers, and facilities have worked hard to implement changes that would facilitate correct coding through clear documentation and well-formatted templates. 

The level of E/M service reported is determined by the overall scoring of the following three MDM elements when combined so that two of the three meet or exceed the same level of complexity: 

  • Number and Complexity of Problems Addressed at the Encounter (Problems)
  • Amount and/or Complexity of Data to be Reviewed and Analyzed (Data)
  • Risk of Complications and/or Morbidity or Mortality of Patient Management (Risk)

While each element consists of specific rules and guidelines for scoring, the focus of this article is about identifying and scoring the third element or risk.

Understanding the terminology associated with the element of risk will provide a higher level of understanding of the consequences of certain types of patient management, which include: 

  • Complications
    • Consequences of patient management decisions that put the patient at greater risk
  • Morbidity
    • A state of illness or functional impairment associated with the patient’s condition that may last a long time and/or never improve
  • Mortality
    • A high possibility of death with or without patient management

A high-risk patient is identified as a patient who, due to the complexity of co-morbid or chronic, unstable medical conditions or even a severe acute illness or traumatic injury, finds themselves at risk of major complications (with or without treatment), worsening disease and disability, or even death. The decisions made by the treating provider can have positive or negative outcomes, and the better we understand the documentation and coding requirements for scoring these high-risk levels of service, the better our coding outcomes will be as well.

The CPT guidelines identify the following bullet points defining the profile of a high-risk patient, including:

  • Drug therapy requiring intensive monitoring for toxicity
  • Decision regarding elective, major surgery with identified patient or procedure risk factors
  • Decision regarding emergency major surgery
  • Decision regarding hospitalization or escalation of hospital level of care
  • Decision not to resuscitate or to de-escalate care because of poor prognosis
  • Parenteral controlled substances

Throughout the revision of the CPT E/M coding guidelines, the American Medical Association (AMA) has published the E/M-associated terminology definitions to help reduce confusion and improve clarity in code selection. The new guidelines provide additional information for most of these bulleted items and many articles and webinars have been published to assist in educating providers, coders, and payers alike. 

Documenting the right details is the key factor in selecting the correct code and those details are defined in an upcoming Find-A-Code webinar, free to the public, in which a thorough discussion of each bulleted item is reviewed as well as the overall scoring process.

New bulleted items added to the MDM table for 2023, include the decision regarding hospitalization or escalation of hospital-level care and parenteral controlled substances. Join us for a free webinar where we review each of these bulleted high-risk issues, define them, and discuss the key documentation points to look for when scoring E/M services.

Click HERE to sign up today for this FREE webinar. "Looking Closer at High Risk EM Medical Decision Making" scheduled for Thursday, "June 8, 2023" @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET.