Current E/M
Risk of complications, morbidity and/or mortality of patient management
MDM element of Risk: In a nutshell
The level of risk is based on the risk associated with selecting a management option and decisions made during the visit related to the patient’s problem(s), diagnostic procedure(s), and treatment option(s).
Determining the level of risk involves considering all possible management and treatment options, selected or not.
There are four levels of risk: straightforward, low, moderate, and high.
The element of risk
The level of risk associated with a patient visit will be different for each encounter. The choice for this element includes the nature of the presenting problem and the morbidity and/or mortality of the problem(s) being treated. You can also include treatment options discussed with the patient even if they did not end up occurring. For example, a decision to perform surgery includes consideration and discussion of alternative treatment options with the patient which factors into calculating element of risk.
Determining the level of risk
As with the other elements of MDM, there are four distinct levels of risk of complications, morbidity and/or mortality of patient management: straightforward, low, moderate, and high complexity.
See the table below as a guide for each level of complexity for this element of MDM.
| Level of MDM (Based on 2 out of 3 Elements of MDM) | Risk of Complications and/or Morbidity or Mortality of Patient Management | |
|---|---|---|
Straightforward |
Minimal risk of morbidity from additional diagnostic testing or treatment |
|
Low |
Low risk of morbidity from additional diagnostic testing or treatment Examples may include, but are not limited to: • Recommendation of over-the-counter medication • Decision regarding minor surgery with no identified patient or procedure risk factors* |
|
Moderate |
Moderate risk of morbidity from additional diagnostic testing or treatment Examples may include, but are not limited to: • Prescription drug management • Decision regarding minor surgery with identified patient or procedure risk factors • Decision regarding elective major surgery without identified patient or procedure risk factors • Diagnosis or treatment significantly limited by social determinants of health* * Per the American Medical Association (AMA), Identified patient or procedural risk factors are those risk identified in the medical record that are above and beyond those inherent to and typically associated with the minor procedure. |
|
High |
High risk of morbidity from additional diagnostic testing or treatment Examples may include, but are not limited to: • 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 • Decision not to resuscitate or to de-escalate care because of poor prognosis |
|
Now that you have selected the level of the risk, you will need at least one additional MDM element from the list below before determining the overall level of MDM for the encounter:
Ready to quantify the overall level of MDM? Use the E/M Office Visit Level of MDM Table (PDF) to determine the level of MDM and code for the encounter.
Use the Current E/M coding tool
The Academy has released a version of the E/M coding tool for the current guidance, to help dermatologists select the appropriate code.
Use the tool
You can test your knowledge of E/M coding by taking a short Academy quiz, or see other coding quizzes.
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