Risk Assessment: Moderate

The Risk assessment is stratified as:

• Minimal
• Low
• Moderate
• High

In order for an assessment to be moderate risk, there has to be one element of any of the 3 categories presented.

A. Presenting Problem

• One or more chronic illness with mild exacerbation or progression
• Two or more stable chronic illnesses
• Undiagnosed new problem with uncertain prognosis
• Acute illness with systemic symptoms
• Acute complicated injury

B. Diagnostic procedure

• Physiologic tests under stress
• Diagnostic endoscopies with no identified risk factors
• Deep needle or incisional biopsies
• Cardiovascular imaging studies with contrast and no identified risk factors
• Obtain fluid from body cavity

C. Management options selected

• Minor surgery with identified risk factors
• Elective major surgery with no risk factors
• Prescriptions drug management
• Therapeutic nuclear medicine
• IV fluids with additives
• Closed treatment of fracture or dislocations without manipulation

Bibliography

Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. "Evaluation and Management Services." Accessed April 30, 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 24. Evaluation and Management Documentation 9. Risk Assessment: Moderate Risk”. SMO Blog (blog). April 27, 2020. https://hive.blog/hive-163521/@secondmedicalop/clinical-documentation-improvement-series-24-evaluation-and-management-documentation-9-risk-assessment-moderate-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

- Clinical Documentation Improvement Series 23. Evaluation and Management Documentation 8. Risk Assessment: Low Risk

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