Level of Risk (2024)

Level of Risk

Risk is determined by referring to the table of risk below which describes four levels of medical jeopardy:

1. Minimal Risk

This is the lowest level of risk possible. It is required for benign encounters such as a level 1 new office patient (99201) or a level 2 office visit with established patient (99202).

This level of risk requires

• One self-limited or minor problem (e.g., insect bite, cold)

Diagnostic Procedure(s)

• Lab tests

• Chest X-ray

• EKG/EEG

• Urinalysis

• Ultrasound/Echocardiography

• KOH prep

Management Options Selected

• Rest

• Gargles

• Elastic bandages

• Superficial dressings

2. Low Risk

This is the second lowest level of risk. Although marginally more serious than Minimal Risk encounters, Low Risk patients are generally quite healthy. Many physicians are surprised to learn that this is the level of risk required for the so-called “routine” level 3 office follow-up visit (99213).

This level of risk requires

• Two or more self-limited or minor problems

• One stable chronic illness

• Acute uncomplicated illness or injury (allergic rhinitis, ankle sprain, cystitis)

Diagnostic Procedure(s)

• Physiologic tests not under stress (e.g., PFTs)

• Non-cardiovascular imaging studies with contrast (e.g., barium enema)

• Superficial needle biopsies

• ABGs

• Skin biopsies

Management Options Selected

• Over-the-counter drugs

• Minor surgery with no identified risk factors

• Physical therapy

  See Also

  The Four Elements of a Risk AssessmentRisk Factors in Health and Disease: What are risk factors?Conducting a Risk Assessment4 Types of Risk Categories in Project Risk Management

• Occupational therapy

• IV fluids without additives

3. Moderate Risk

This is the second highest level of risk. However, a cursory review of the qualifications for this level of medical jeopardy reveals that these patients are usually not very sick.This is the level of risk required for a level 2 hospital progress note (99232) or a level 4 office follow-up visit (99214).

This level of risk requires

• One or more chronic illness with mild exacerbation or progression

• Two or more stable chronic illnesses

• Undiagnosed new problem with uncertain prognosis (e.g., lump in breast)

• Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis

• Acute complicated injury (e.g., head injury with brief loss of consciousness)

Diagnostic Procedure(s)

• Physiologic tests under stress (e.g., cardiac stress test)

• Diagnostic endoscopies with no identified risk factors

• Deep needle or incisional biopsies

• Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac catheterization)

• Obtain fluid from body cavity (e.g., LP, thoracentesis, culdocentesis)

Management Options Selected

• Minor surgery with identified risk factors

• Elective major surgery with no risk factors

• Prescriptions drug management

• Therapeutic nuclear medicine

• IV fluids with additives

• Closed treatment of fracture or dislocations without manipulation

4. High Risk

This is the highest level of risk. This level of risk is required for a level 3 admission H&P (99223), a level 5 office follow-up visit (99215) and a level 3 hospital progress note (99233) .

This level of risk requires

• One or more chronic illness with severe exacerbation or progression

• Acute or chronic illness or injuries which pose a threat to life or bodily function (e.g.,
  multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive
  severe rheumatoid arthritis, psychiatric illness with potential threat to self or others,
  peritonitis, acute renal failure)

Diagnostic Procedure(s)

• Cardiovascular imaging studies with contrast with identified risk factors

• Cardiac EP testing

• Diagnostic endoscopies with identified risk factors

• Discography

Management Options Selected

• Elective major surgery with identified risk factors

  See Also

  Four Key Elements of an Effective Risk Management Program

• Emergency major surgery

• Parenteral controlled substances

• Drug therapy requiring intensive monitoring for toxicity

• Decision not to resuscitate or to de-escalate care because of poor prognosis

When referring to the table, the level of risk is determined by examining three separate dimensions of the encounter:

• Presenting Problems

• Diagnostic Procedures

• Management Options Selected

Presenting Problems and Level of Risk

Minimal Risk

• One self-limited or minor problem (e.g., insect bite, cold)

Low Risk

• Two or more self-limited or minor problems

• One stable chronic illness

• Acute uncomplicated illness or injury (allergic rhinitis, ankle sprain, cystitis)

Moderate Risk

• One or more chronic illness with mild exacerbation or progression

• Two or more stable chronic illnesses

• Undiagnosed new problem with uncertain prognosis (e.g., lump in breast)

• Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis

• Acute complicated injury (e.g., head injury with brief loss of consciousness)

High Risk

• One or more chronic illness with severe exacerbation or progression

• Acute or chronic illness or injuries which pose a threat to life or bodily function (e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure)

Diagnostic Procedures and Level of Risk

Minimal Risk

• Lab tests

• Chest X-ray

• EKG/EEG

• Urinalysis

• Ultrasound/Echocardiography

Low Risk

• Physiologic tests not under stress (e.g., PFTs)

• Non-cardiovascular imaging studies with contrast (e.g., barium enema)

• Superficial needle biopsies

• ABGs

• Skin biopsies

Moderate Risk

• Physiologic tests under stress (e.g., cardiac stress test)

• Diagnostic endoscopies with no identified risk factors

• Deep needle or incisional biopsies

• Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac catheterization)

• Obtain fluid from body cavity (e.g., LP, thoracentesis, culdocentesis)

High Risk

• Cardiovascular imaging studies with contrast with identified risk factors

• Cardiac EP testing

• Diagnostic endoscopies with identified risk factors

Management options selected and level of risk

Minimal Risk

• Rest

• Gargles

• Elastic bandages

• Superficial dressings

Low Risk

• Over-the-counter drugs

• Minor surgery with no identified risk factors

• Physical therapy

• Occupational therapy

• IV fluids without additives

Moderate Risk

• Minor surgery with identified risk factors

• Elective major surgery with no risk factors

• Prescriptions drug management

• Therapeutic nuclear medicine

• IV fluids with additives

• Closed treatment of fracture or dislocations without manipulation

High Risk

• Elective major surgery with identified risk factors

• Emergency major surgery

• Parenteral controlled substances

• Drug therapy requiring intensive monitoring for toxicity

• Decision not to resuscitate or to de-escalate care because of poor prognosis

Coding Tip: The E/M guidelines explicitly state that the highest level of risk present in any one of the above categories determines the overall risk of the encounter. Physicians often underestimate the level of risk as defined by the E/M guidelines.