2021 E/M update Get to know: MDM risk category

Why This Topic Matters

Risk is a core part of determining the overall medical decision-making level under the 2021 E/M office visit guidelines. Understanding the updated risk framework helps documentation teams recognize what information may need to be captured in the note and how the guideline changes affect review of patient management.

Article Sections

1. Overview of the 2021 E/M risk element

   Introduces the risk component of medical decision-making in the 2021 office visit guidelines and explains its place within the updated framework. It also discusses how risk is evaluated in relation to patient management considerations on the date of service.

2. Minimal and low risk

   Describes the lowest risk categories in general terms and relates them to documentation themes referenced in the article. The section contrasts the broad documentation expectations associated with these lower levels.

3. Moderate risk

   Covers the moderate risk category and the kinds of general documentation themes associated with it. The section also introduces social determinants of health as part of the updated guidance.

4. High risk

   Summarizes the high risk category and the broader documentation themes linked to more serious patient management decisions. It includes the article’s discussion of hospitalization, major surgery, and care-escalation considerations.

5. Drug therapy requiring intensive monitoring for toxicity

   Explains the special monitoring concept highlighted in the 2021 guidance and how it differs from more routine monitoring discussions. The section focuses on the general type of oversight described in the article.