Risk Assessment: High
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 severe exacerbation or progression
- Acute or chronic illness or injuries which pose a threat to life or bodily function
B. Diagnostic procedure
- Cardiovascular imaging studies with contrast with identified risk factors
- Cardiac EP testing
- Diagnostic endoscopies with identified risk factors
- Discography
C. 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
Bibliography
Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. "Evaluation and Management Services." Accessed May 2, 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