From the brief excerpt you provide, I get moderate risk for the PROCEDURE.
Ellective Major Surgery with no identified risk factors
The risk factors the table is referring to are patient co-morbidities, NOT the risks of the surgery/procedure. So if the patient has DM, for example, or is on coumadin, or has a congenital heart anomaly ... those are identified risk factors.
HOWEVER ... it is possible he is looking at the metastic breast disease with a new adrenal mass as "One or more chronic illnesses with severe exacerbation, progression or side effects of treatment." . This would fall under high risk.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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