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Documentation Guidelines for CPT Evaluation and Management Services                         

3. Table of Risk

Total is equal to the highest level of risk in any one category.

This table is to be used as a guideline for risk. It is not considered to be comprehensive.

TOTAL = _________

(Total = highest risk in any one category)

Level of Risk Presenting
Problem(s)
Diagnostic
Procedure(s) Ordered
Management
Options Selected

Minimal

One self-limited or minor problem, e.g., cold, insect bite, tinea corpis

Laboratory tests requiring venipuncture

Chest x-rays

EKG/EEG

Urinalysis

Ultrasound, e.g., echo-cardiography

KOH prep

Rest

Gargles

Elastic bandages

Superficial dressings

Low

Two or more self-limited or minor problems

One stable chronic illness, e.g., well controlled hypertension or non-insulin dependent diabetes, cataract, BPH

Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain

Physiologic tests not under stress, e.g., pulmonary function tests

Non-cardiovascular imaging studies with contrast, e.g., barium enema

Superficial needle biopsies

Clinical laboratory tests requiring arterial puncture

Skin biopsies

Over-the-counter drugs

Minor surgery with no identified risk factors

Physical therapy

IV fluids without additives

Moderate

One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment

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

Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test

Diagnostic endoscopies with no identified risk factors

Deep needle or incisional biopsy

Cardiovascular imaging studies with contrast and no identified risk factors, e.g., arteriogram, cardiac catheterization

Obtain fluid from body cavity, e.g., lumbar puncture, thora- centesis, culdocentesis

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

High

One or more chronic illnesses with severe exacerbation, pro- gression, or side effects of treatment

Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis,

psychiatric illness with potential threat to self or others,

peritonitis,

acute renal failure

An abrupt change in neurologic status, e.g., seizure, TIA, weakness, or sensory loss

Cardiovascular imaging studies with contrast with identified risk factors

Cardiac electrophysiological tests

Diagnostic endoscopies with identified risk factors

Discography

Elective major surgery (open, percutaneous or endoscopic) with identified risk factors

Emergency major surgery (open, percutaneous or endoscopic)

Parenteral controlled substances

Drug therapy requiring intensive monitoring for toxicity

Decision not to resuscitate or to deescalate care because of poor prognosis

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