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.