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.

View the Office E/M Coding Changes Guide