Clinical Documentation Improvement Series 25. Evaluation and Management Documentation 10. Risk Assessment: High Risk
(Edited)
Risk Assessment: High
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 severe exacerbation or progression
- Acute or chronic illness or injuries which pose a threat to life or bodily function
B. Diagnostic procedure
- Cardiovascular imaging studies with contrast with identified risk factors
- Cardiac EP testing
- Diagnostic endoscopies with identified risk factors
- Discography
C. Management options selected
- Elective major surgery with identified risk factors
- Emergency major surgery
- Parenteral controlled substances
- Drug therapy requiring intensive monitoring for toxicity
- Decision not to resuscitate or to de-escalate care because of poor prognosis
Bibliography
Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. "Evaluation and Management Services." Accessed May 2, 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 25. Evaluation and Management Documentation 10. Risk Assessment: High Risk”. SMO Blog (blog). May 2, 2020. https://hive.blog/hive-163521/@secondmedicalop/clinical-documentation-improvement-series-25-evaluation-and-management-documentation-10-risk-assessment-high-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
- Clinical Documentation Improvement Series 24. Evaluation and Management Documentation 9. Risk Assessment: Moderate Risk
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