E/M Weekly Tip: Risk of Significant Complications, Morbidity and/or Mortality (Risk Assessment)
Published 08/03/2020
The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the following categories:
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Presenting problem(s)
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Diagnostic procedure(s)
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Possible management options
The highest level of risk in any one category determines the overall risk. The level of risk of significant complications, morbidity and/or mortality can be:
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Minimal
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Low
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Moderate
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High
Please see CMS Documentation Guidelines for Evaluation and Management Services on the CMS website for more information.