Wiki Risk for office visits

[shanamarie]

I’m struggling with determining risk for new/established patient visits. If it’s something that’s on the AMA E/M sheet then I’m fine, but if it’s not then I struggle at times, and would like to get better at that. Do you recommend that providers document risk for each visit using terms like low, moderate or high?

 

[TThivierge]

Hi Shanamarie,
First I would determine if new or established patients status. Then why are they being seen ..is it for a ongoing chronic illness which need quarterly testing of lab and constant med refills? Examples like DM, heart conditions, sleep dx G47, Depression, Obesity,HTN, Arthritis, Cancers, CHKD, Lumbar Pain, GERD common illnesses. But some disease are more risky than others. Also it is determined by documentation , meds given, tests, given if illness with checking pt. out ever 6 months or so. Then naturally some patients need emergency treatment such as Fx, lacerations, muscle spasms from accident and range of pain in hurting toes& feet, tummy, headache to name a few. Read the ROS it helps and the HPI on the treatment record for the day plus medications given, xrays, labs,Etc. Also their past medical history can be added if it is related to current problem. Face to face time counts and follow up on chronic conditions may not be length treatment and aftercare after surgery or dressing . Cancer, Cardiac and Forever Ds, Amputations, & Chronic Conditions seem to be related care is always rated high in auditing moderate risk but depends on illness, doc documentation and length of time. Also count if one or more dx codes when patient is getting treatment adds to risk and evaluation of E&M code. Count if current provider must read other specialist physician consult reports counts to. Asking your providers to use the terms low, high or moderate may help but each pt. has different problems trying to document Plus they probably use template to help them.
Well did I help you understand a bit more on risk? I hope so.
Lady T
PS Sometimes docs will write pt has history of GERD but you keep reading he is talking about current chronic ongoing illness. If doc use history of for a true past illness it helps put a date rage like ..Patient had lung cancer 10 years ago or Arthritis of knee 6 months ago. This notation lets you know it is in the past, (dxZ86 or Z87) not today s treatment problem. But can always look at NOC or Chief Complaint (CC).

 

[jkyles]

I’m struggling with determining risk for new/established patient visits. If it’s something that’s on the AMA E/M sheet then I’m fine, but if it’s not then I struggle at times, and would like to get better at that. Do you recommend that providers document risk for each visit using terms like low, moderate or high?

Yes, I think that's the best way to do it.

The AMA has consistently said that for the new guidelines, the treating provider determines risk. For example

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)

The AMA also clarified that the examples in the risk column were just examples, not a definitive list and did not provide examples for straightforward and low. It has always seemed to me that the easiest thing for everyone involved would be if the provider indicated what the risk is. They could add a couple of lines explaining their thinking too. But the coder should never have to guess what the risk is.