2023 Coding medical decision making – Risk

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Q: Can you please provide the new definitions regarding the risk category in medical decision making?

A: As a continuation of previous articles, the following definitions were given for the Evaluation and Management (E/M) 2023 guidelines for clarification of some gray areas.

Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. 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.

As you can see, the level of risk is dependent on the provider’s thought process, which isn’t easy for them to document, and some providers don’t believe this is needed for other providers who see the patient. However, we need to explain that if there is anything that changes the risk for this patient that is outside the norm, it needs to be documented so they receive the applicable credit for that patient’s risk.

Drug therapy requiring intensive monitoring for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent but may be patient-specific in some cases. Intensive monitoring may be long-term or short-term. Long-term intensive monitoring is not performed less than quarterly. The monitoring may be performed with a laboratory test, a physiologic test, or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of MDM in an encounter in which it is considered in the management of the patient. An example may be monitoring for cytopenia in the use of an antineoplastic agent between dose cycles. Examples of monitoring that do not qualify include monitoring glucose levels during insulin therapy, as the primary reason is the therapeutic effect (unless severe hypoglycemia is a current, significant concern); or annual electrolytes and renal function for a patient on a diuretic, as the frequency does not meet the threshold.

This has always been an area that leads to questions, and this definition helps answer some. Providers need to know that this element isn’t met for situations where the primary monitoring is for the effect of the therapy. That’s the best question to ask a provider when they want to know if this element has been met in the Risk category of medical decision making.

Renee Dowling is a compliance auditor at Sansum Clinic, LLC, in Santa Barbara, California.