American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Element 3: Risk

3. The risk of complications and/or morbidity or mortality of patient management.

CPT has developed an extensive definition for 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 purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization."

The MDM table provides examples of risk for moderate and high MDM that many surgeons can relate to, such as a decision regarding minor surgery with identified patient or procedure risk factors or a decision regarding elective major surgery without identified patient or procedure risk factors.

Office/Outpatient E/M Visit CPT Code

3) Risk of Complications and/or Morbidity or Mortality of Patient Management

99211 Not applicable
99202
99212
Minimal risk of morbidity from additional diagnostic testing or treatment
99203
99213
Low risk of morbidity from additional diagnostic testing or treatment

99204
99214

Moderate risk of morbidity from additional diagnostic testing or treatment

Examples only:

  • Prescription drug management
  • Decision regarding minor surgery with identified patient or procedure risk factors
  • Decision regarding elective major surgery without identified patient or procedure risk factors
  • Diagnosis or treatment significantly limited by social determinants of health

99205
99215

High risk of morbidity from additional diagnostic testing or treatment

Examples only:

  • Drug therapy requiring intensive monitoring for toxicity
  • Decision regarding elective major surgery with identified patient or procedure risk factors
  • Decision regarding emergency major surgery
  • Decision regarding hospitalization
  • Decision not to resuscitate or to de-escalate care because of poor prognosis

View the Office E/M Coding Changes Guide