Question 2021 MDM Risk

kimberagame

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Hello everyone,

I was curious how other coders were handling risk with the new 2021 guidelines. The minimal and low categories no longer have examples, and the guidelines state that the risk levels do not need to be defined, as providers will know based on their training whether risk is minimal, low, moderate, or high. The speaker at a presentation I attended suggested that providers would need to tell us risk levels.

Is this anyone's plan? Or is everyone going to determine risk the same way they always did? Thanks for any feedback!
 

Bernadette10

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I'm wondering this too for the minimal vs low risk. For example, for the below would this be minimal or low? Complexity of problem is low for an acute, uncomplicated injury. I'm thinking risk is minimal, or could it be low? It would have been so helpful if the guidelines had some examples for this. Feeling very frustrated.
Ortho clinic visit
Diagnosis: Muscle tendon strain, LT wrist. Patient was given a forearm splint at his previous ER visit, which he has been wearing.
No data.
Plan: I would like him to take it easy for 2 weeks, and we'll see him back in 2 weeks and reevaluate him for work at that point. He needs rest to resolve the problem. This can last for 6-12 weeks, and hopefully he'll be on the short end of that.
 
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Jessim929

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PRS Network gave a pocket card at one of their webinars, and rest falls into the minimal risk category. (venipuncture and ultrasounds are other examples as well.) OTC meds, minor surgery without risk, superficial needle biopsy, and arterial stick lab work are low risk examples given.
 

Bernadette10

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Someone gave me this which is a good reference:
FAQs: 2021 Office-Based E/M Changes (aap.org)

Q. What is risk in relation to the MDM table?

A. CPT defines this as the risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. It is the risk of treatment versus non-treatment.
 
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