E/M Weekly Tip: Risk of Significant Complications, Morbidity and/or Mortality (Risk Assessment)

The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the following categories:

  • Presenting problem(s)
  • Diagnostic procedure(s)
  • 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:

  • Minimal
  • Low
  • Moderate
  • High

Please see CMS Documentation Guidelines for Evaluation and Management Services on the CMS website for more information.