Level of Risk

Level of Risk

Risk is determined by referring to the table of risk below which describes four levels of medical jeopardy:

1. Minimal Risk

This is the lowest level of risk possible. It is required for benign encounters such as a level 1 new office patient (99201) or a level 2 office visit with established patient (99202).

This level of risk requires ONE element in ANY of the following three categories:

Presenting Problem(s)

One self-limited or minor problem (e.g., insect bite, cold)

Diagnostic Procedure(s)

Lab tests
Chest X-ray
EKG/EEG
Urinalysis
Ultrasound/Echocardiography
KOH prep

Management Options Selected

Rest
Gargles
Elastic bandages
Superficial dressings

2. Low Risk

This is the second lowest level of risk. Although marginally more serious than Minimal Risk encounters, Low Risk patients are generally quite healthy. Many physicians are surprised to learn that this is the level of risk required for the so-called “routine” level 3 office follow-up visit (99213).

This level of risk requires ONE element in ANY of the following three categories:

Presenting Problem(s)

Two or more self-limited or minor problems
One stable chronic illness
Acute uncomplicated illness or injury (allergic rhinitis, ankle sprain, cystitis)

Diagnostic Procedure(s)

Physiologic tests not under stress (e.g., PFTs)
Non-cardiovascular imaging studies with contrast (e.g., barium enema)
Superficial needle biopsies
ABGs
Skin biopsies

Management Options Selected

Over-the-counter drugs
Minor surgery with no identified risk factors
Physical therapy
Occupational therapy
IV fluids without additives

3. Moderate Risk

This is the second highest level of risk. However, a cursory review of the qualifications for this level of medical jeopardy reveals that these patients are usually not very sick. This is the level of risk required for a level 2 hospital progress note (99232) or a level 4 office follow-up visit (99214).

This level of risk requires ONE element in ANY of the following three categories:

Presenting Problem(s)

One or more chronic illness with mild exacerbation or progression
Two or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis (e.g., lump in breast)
Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis
Acute complicated injury (e.g., head injury with brief loss of consciousness)

Diagnostic Procedure(s)

Physiologic tests under stress (e.g., cardiac stress test)
Diagnostic endoscopies with no identified risk factors
Deep needle or incisional biopsies
Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac catheterization)
Obtain fluid from body cavity (e.g., LP, thoracentesis, culdocentesis)

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

4. High Risk

This is the highest level of risk. This level of risk is required for a level 3 admission H&P (99223), a level 5 office follow-up visit (99215) and a level 3 hospital progress note (99233) .

This level of risk requires ONE element in ANY of the following three categories:

Presenting Problem(s)

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 (e.g.,
multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive
severe rheumatoid arthritis, psychiatric illness with potential threat to self or others,
peritonitis, acute renal failure)

Diagnostic Procedure(s)

Cardiovascular imaging studies with contrast with identified risk factors
Cardiac EP testing
Diagnostic endoscopies with identified risk factors
Discography

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

Table of Risk: Use highest level of risk based on ONE element from ANY of the categories below


Risk Level	Presenting Problems	Diagnostic Procedures	Management Options Selected
Minimal Risk Requires ONE of these elements in ANY of the three categories listed	· One self-limited or minor problem, e.g., cold, insect bite, tinea corporis	Laboratory tests Chest X-rays EKG/EEG Urinalysis Ultrasound/Echocardiogram KOH prep	Rest Gargles Elastic bandages Superficial dressings
Risk Level	Presenting Problems	Diagnostic Procedures	Management Options Selected
Low Risk Requires ONE of these elements in ANY of the three categories listed	Two or more self-limited or minor problems One stable chronic illness, e.g., well controlled HTN , DM2, cataract Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain	Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging studies with contrast, e.g., barium enema Superficial needle biopsy ABG Skin biopsies	Over the counter drugs Minor surgery, with no identified risk factors Physical therapy Occupational therapy IV fluids, without additives
Risk Level	Presenting Problems	Diagnostic Procedures	Management Options Selected
Moderate Risk Requires ONE of these elements in ANY of the three categories listed	Two stable chronic illnesses One chronic illness with mild exacerbation or progression Undiagnosed new problem with uncertain prognosis (e.g., lump in breast) Acute complicated injury, e.g., head injury, with brief loss of consciousness	Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test Diagnostic endoscopies, with no identified risk factors Deep needle, or incisional biopsies Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization Obtain fluid from body cavity, e.g., LP/thoracentesis	Minor surgery, with identified risk factors Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids, with additives Closed treatment of fracture or dislocation, without manipulation
Risk Level	Presenting Problems	Diagnostic Procedures	Management Options Selected
High Risk Requires ONE of these elements in ANY of the three categories listed	One or more chronic illness, with severe exacerbation or progression Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss	Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Discography	Elective major surgery (open, percutaneous, endoscopic), with identified risk factors Emergency major surgery (open, percutaneous, endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate, or to de-escalate care because of poor prognosis

When referring to the table, the level of risk is determined by examining three separate dimensions of the encounter:

Presenting Problems
Diagnostic Procedures
Management Options Selected

Presenting Problems and Level of Risk

Minimal Risk

One self-limited or minor problem (e.g., insect bite, cold)

Low Risk

Two or more self-limited or minor problems
One stable chronic illness
Acute uncomplicated illness or injury (allergic rhinitis, ankle sprain, cystitis)

Moderate Risk

One or more chronic illness with mild exacerbation or progression
Two or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis (e.g., lump in breast)
Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis
Acute complicated injury (e.g., head injury with brief loss of consciousness)

High Risk

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 (e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure)

Diagnostic Procedures and Level of Risk

Minimal Risk

Lab tests
Chest X-ray
EKG/EEG
Urinalysis
Ultrasound/Echocardiography

Low Risk

Physiologic tests not under stress (e.g., PFTs)
Non-cardiovascular imaging studies with contrast (e.g., barium enema)
Superficial needle biopsies
ABGs
Skin biopsies

Moderate Risk

Physiologic tests under stress (e.g., cardiac stress test)
Diagnostic endoscopies with no identified risk factors
Deep needle or incisional biopsies
Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac catheterization)
Obtain fluid from body cavity (e.g., LP, thoracentesis, culdocentesis)

High Risk

Cardiovascular imaging studies with contrast with identified risk factors
Cardiac EP testing
Diagnostic endoscopies with identified risk factors

Management options selected and level of risk

Minimal Risk

Rest
Gargles
Elastic bandages
Superficial dressings

Low Risk

Over-the-counter drugs
Minor surgery with no identified risk factors
Physical therapy
Occupational therapy
IV fluids without additives

Moderate Risk

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

High Risk

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

Coding Tip: The E/M guidelines explicitly state that the highest level of risk present in any one of the above categories determines the overall risk of the encounter. Physicians often underestimate the level of risk as defined by the E/M guidelines.