# 2021 E&M guidelines for Risk of Complications and or Morbidity



## wynonna (Jan 7, 2021)

Hello:
On the far right column of the auditing tool for 2021, we have "Risk of Complications and/or Morbidity or Mortality of Patient management (additional diagnostic testing or treatment"

How do we differentiate between "MInimal Risk of morbidiity from additional diagnostic testing or treatment".. vs "Low risk of morbidity from additional diagnostic testing or treatment"
What are the criteria?  What is minimal risk?  What is low risk?
thank you my friends.


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## beulastella (Jan 7, 2021)

Hi, 
My Understanding is below 
May be correct or wrong, correct me if i am wrong as it is learning for everyone.
Minimal risk - W/o treatment the condition can be recovered completely( No risk of Permanent illness or functional impairment (Morbidity))
Low risk - With treatment the condition recovers completely with out any permanent or residuals ( will be in little risk if not treated but not life threatening or permanent illness or functional impairment (Morbidity))
Moderate risk - With treatment the condition can be brought back to near normal not exact recovery (if not treated will develop a significant risk for Morbidity ( life threatening or permanent illness or functional impairment ))
High Risk - Though under treatment the risk of morbidity is significant say for example HF though under treatment may have the risk for death.

Thanks,


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## wynonna (Jan 8, 2021)

Yes, thank you that's helpful.   To me it seems this is a clinical decision and should be documented by the provider. Low mod or High risk, that is.
In theme meantime I'm using g/l  that OTC minor surgeries,, PT, OT, IV fluids w/o additives all are low risk.


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