home exercise program- level for Risk

[nbassinger23]

Hello,

I am currently reviewing a patients (13yo) report and a home exercise program was given for a strain, as well as shoulder stretch phase 1 twice a day, and to follow up via televisit.

Would the home exercise program fall under which level Straightforward Risk or Low Risk?

 

[Sarah Ann]

Can I just say this- the 2023 E/M "Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purpose of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter." ◄Page 18 2023 guidelines. I think with that it's incumbent on the clinician to state the risk. Using the 2023 MDM table. This is what I'm reading.

 

[jkyles]

Hi there, if the risk isn't documented, you need to ask the treating clinician. As noted above, the current CPT guidelines make it clear that the treating clinician determines risk. Coders should not have to guess, but clinicians may need a reminder that they must spell it out.

The same applies to complexity of the problem addressed.