Clinical Documentation Improvement Series 23. Evaluation and Management Documentation 8. Risk Assessment: Low Risk
Risk Assessment: Low
The Risk assessment is stratified as:
- Minimal
- Low
- Moderate
- High
In order for an assessment to be low risk, there has to be one element of any of the 3 categories presented.
A. Presenting Problem
- Two or more self-limited or minor problems
- One stable chronic illness
- Acute uncomplicated illness or injury
B. Diagnostic procedure
- Physiologic tests not under stress
- Non-cardiovascular imaging studies with contrast
- Superficial needle biopsies
- ABGs
- Skin biopsies
C. Management options selected
- Over-the-counter drugs
- Minor surgery with no identified risk factors
- Physical therapy
- Occupational therapy
- IV fluids without additives
Bibliography
Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. "Evaluation and Management Services." Accessed April 27, 2020. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
Marco A. Ramos MD, CCDS
In order to quote from this article in bibliography, Chicago style, please use the following:
Ramos, Marco. “Clinical Documentation Improvement Series 23. Evaluation and Management Documentation 8. Risk Assessment: Low Risk”. SMO Blog (blog). April 27, 2020. https://hive.blog/hive-163521/@secondmedicalop/clinical-documentation-improvement-series-23-evaluation-and-management-documentation-8-risk-assessment-low-risk
Links to the Previous Posts in this Evaluation and Management Series
- Clinical Documentation Improvement Series 16. Evaluation and Management Documentation 1. Components of the History of Present Illness
- Clinical Documentation Improvement Series 17. Evaluation and Management Documentation 2. Individual Systems of the Review of Systems
- Clinical Documentation Improvement Series 18. Evaluation and Management Documentation 3. Areas of the Past, Family and Social History
- Clinical Documentation Improvement Series 19. Evaluation and Management Documentation 4. Organ Systems of the Physical Exam
- Clinical Documentation Improvement Series 20. Evaluation and Management Documentation 5. Problem Points of the Medical Decision Making
- Clinical Documentation Improvement Series 21. Evaluation and Management Documentation 6. Problem Points of the Medical Decision Making
- Clinical Documentation Improvement Series 22. Evaluation and Management Documentation 7. Risk Assessment: Minimal Risk
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