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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