General Surgery Coding Alert

Question: How do we know the “risk” involved in an encounter so we can understand the level of medical decision making (MDM)?

Kentucky Subscriber

Answer: The physician or other qualified healthcare professional documenting an encounter should state the level of risk.

CPT^® does not provide any clear definition of risk level. Consider this verbiage found in the E/M 2021 Errata and Technical corrections:

“The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based on the usual behavior and thought processes of a physician or other qualified healthcare professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities).”

Bottom line: The surgeon who evaluates the patient is the one who is qualified to judge the specific patient factors that make a procedure high, moderate, or low risk. Providers should be aware of the need to document the level of risk to allow for appropriate code assignment.