Risk Assessment: Moderate
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 mild exacerbation or progression
- Two or more stable chronic illnesses
- Undiagnosed new problem with uncertain prognosis
- Acute illness with systemic symptoms
- Acute complicated injury
B. Diagnostic procedure
- Physiologic tests under stress
- Diagnostic endoscopies with no identified risk factors
- Deep needle or incisional biopsies
- Cardiovascular imaging studies with contrast and no identified risk factors
- Obtain fluid from body cavity
C. 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
Bibliography
Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. "Evaluation and Management Services." Accessed April 30, 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
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