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Wiki 2021 E/M MDM Element #3 - Minimal and Low Risk

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deajsharichardson

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Does anyone have any clarification on the new 2021 E/M Guidelines when it comes to Element #3? I am having trouble being able to choose between minimal risk and low risk for a patient because they do not have specific bullet options in those two categories to pick from. For example, if a provider is referring a patient out to a hand specialist, does this qualify as a minimal or low risk patient for Element #3? He referred and also did a history on that patient's issue; therefore, there is a problem addressed but the provider is not doing anything for the patient other than referring them out. If you have any clarification, please attach resources that you found your information from. Anything helps!
 
deaowens@yahoo.com said:
Does anyone have any clarification on the new 2021 E/M Guidelines when it comes to Element #3? I am having trouble being able to choose between minimal risk and low risk for a patient because they do not have specific bullet options in those two categories to pick from. For example, if a provider is referring a patient out to a hand specialist, does this qualify as a minimal or low risk patient for Element #3? He referred and also did a history on that patient's issue; therefore, there is a problem addressed but the provider is not doing anything for the patient other than referring them out. If you have any clarification, please attach resources that you found your information from. Anything helps!
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Problem addressed: A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.
 
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