EM Coding Alert

Learn why documentation matters when coding based on risk assessment.

In this final installment of the series, the expert-driven HEALTHCON 2026 presentation, “Expert E/M Insights: Cracking the Code of the Three Key Elements of MDM,” led by Pam D’Apuzzo, CPC, ACS EM, ACS MS, CPMA, Betsy Nicoletti, MS, CPC, and Debra Rossi, CPC, CPMA, goes into further detail regarding the risk of complications and morbidity or mortality in relation to patient management.

Medical decision making (MDM) can be one of the most challenging aspects of evaluation and management (E/M) code selection. When time is not being used to determine the level of service, providers must meet at least two of the three MDM elements to support the reported code, which makes accurate evaluation of problems addressed, data reviewed, and risk levels especially important. Coders play a critical role in this process, carefully analyzing documentation to ensure the MDM level is supported and that the service reported accurately reflects the physician’s work. Proper review of these elements helps promote coding accuracy, reduces compliance risks, and supports appropriate reimbursement.

To help coders confidently assess one of the most confusing components, Nicoletti offered practical guidance on determining risk and applying it appropriately when selecting the E/M service level.

Understand Risk More Clearly

During her presentation, Nicoletti described risk as it relates to E/M as the probability or consequences of patient management decisions that are made during the encounter. Each of these risks considers the following:

• Decisions about diagnostic procedures
• Decisions regarding treatment
• Patient comorbidities or conditions affecting their care

Remember: All documentation should clearly detail the thought process of the provider behind the risk assessment of the patient.

One important contributing factor when it comes to selecting the level of service is understanding the difference between mortality (risk of dying) and morbidity (risk of negative consequences of the treatment). Understanding this element is an assessment of how likely it is that a test or treatment itself will harm a patient.

According to Nicoletti, patients can also play an important role in this aspect. For example, “there are times when a practitioner documents their clinical thinking and says, ‘This is really what we recommend you do today,’ and the patient may not want to comply,” she said. Noncompliance can also contribute to increased risk to the patient.

Learn the Different Types of Risk

Nicoletti started with examples of minimal types of risk like labs, X-rays, ultrasounds, and electrocardiograms (ECGs). Other types of treatment options that carry a minimal amount of risk include procedures like skin tag or wart removal, and treatments suggested like bed rest or an increase in fluid intake.

Low risk assessment may include the following treatments or evaluations:

• Physical therapy (PT) and occupational therapy (OT)
• Physiological tests
• Simple procedures without patient identified risk factors
• Over-the-counter (OTC) medications
• Referrals

Nicoletti went on to explain why she places referrals in this category, “Say you have a patient who comes into primary care, and the physician finds that they have new onset [atrial fibrillation] (AFib), so they refer the patient to cardiology. The risk of AFib is the first element.”

Moderate risk assessment includes but is not limited to the following treatments or evaluations:

• Minor surgery with identified risk factors
• Major surgery without identified risk factors
• Prescription medication management (medication must be prescribed, renewed, changed or stopped)

“When it comes to medication management, we know simply pulling the medication list doesn’t count. We can credit the medication when the patient’s condition is being assessed by the practitioner and managed during that encounter … but we need to see the clinical thinking related to it,” said Nicoletti.

High risk assessment includes the following treatments or evaluations:

• Emergency major surgery
• Major surgery with identified risk factors
  • Document the risk factors specifically related to the patient for the procedure recommended
• Drug therapy requiring intensive monitoring
  • Medications with the potential for morbidity or death
  • Monitored for assessment of adverse effects, not therapeutic efficacy
  • Monitoring is credited at the encounter in which the information is used to manage the patient

“We really recommend the practitioners specifically document the risks for each particular patient with each procedure,” said Nicoletti.

Make note: Both elective and emergent procedures can be minor or major.

See How SDOH May Contribute

As providers evaluate risk during an encounter, they should also consider factors beyond the patient’s medical condition. Social determinants of health (SDOH) can create barriers that affect treatment decisions, access to services, and adherence to care plans. When these circumstances influence patient management, they may elevate the overall risk associated with the encounter and play a role in determining the appropriate E/M level.

“We are looking for critical thinking. If the patient doesn’t have any transportation, they can’t come back for the tests we need [them] to have, because that would show their [SDOH] are limiting either their diagnosis or their treatment. Or due to their homelessness state, the patient doesn’t have a refrigerator, so we can’t order a certain medication,” said Nicoletti.

It’s important to clearly document any limitations that may change the care of a patient or the way the patient is able or available to receive follow-up care or medication.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC