Wiki Level of Risk

[KaylaRieken]

In the Level of Risk box, how do you determine on which to use? Presenting problem, diagnostic procedure ordered, or management option selected?

 

[twizzle]

In the Level of Risk box, how do you determine on which to use? Presenting problem, diagnostic procedure ordered, or management option selected?

You can use any or all of the three criteria depending on what is documented. Usually your overall level of risk will be the highest circled in any box but, depending on company policy, this is not necessarily always the case.
Say a provider prescribes antibiotics to a child that has an ear infection....otitis media. There is a valid argument that the overall level of risk will not be moderate even though a prescription med was given because the nature of the presenting problem (ear infection) is considered an acute uncomplicated problem. Providers will fight tooth and nail to oppose this way of thinking on the basis that any drug that requires a prescription carries an element of risk.....in the case of antibiotics an allergic reaction is a real risk.
Generally, what I described in the first line answers your question hopefully. Just bear in mind that there may be policies in place that override that.

 

[Pathos]

Just to add what @twizzle said, while the Risk Table and other E/M tools are helpful in quantifying the E/M level, Medical Necessity is always king no matter what. Even if the provider has an Rx vs OTC, the overall medical necessity might not be there. This is one of the hardest parts as a non-clinical staff, but a task that has been assigned to us as coders.