How is risk evaluated when selecting a level of E/M service? We know that the risk from additional diagnostic testing/procedures and management is one of the three elements that determines the level of service, when MDM is used. But, how about the risk from the condition itself?
This short video (I always say they’re short and then go on and on….) uses CPT citations to describe the difference between the risk of the condition from the risk from management. The AMA says while they may correlate, they are assessed separately.
The video also discusses
- Risk relates to the reporting practitioner at the reported encounter
- Risk includes the decision to initiate or forego further testing or treatment
- Including management options considered but not selected.
Additional Resources
The Third Element of MDM: Risk of Complications
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