Answer_Book / Documentation_Guidelines_for_EM_Services / RISK_OF_SIGNIFICANT_COMPLICATIONS,_MORBIDITY,_AND_OR_MORTALITY

Why This Topic Matters

Accurate documentation of risk supports consistent E/M leveling and helps distinguish the relative complexity of encounters. The guidance is useful for reviewing whether the record reflects the clinical factors that contribute to a low, moderate, or high risk assessment.

Article Sections

1. Risk of Significant Complications, Morbidity, and/or Mortality

   Introduces the risk component of E/M documentation and explains the factors considered in assessing overall risk.

2. Table of Risk

   Presents a comparison of broad risk levels across presenting problems, diagnostic procedures, and management options.

3. Minimal

   Lists the lowest risk category with representative types of problems, procedures, and management choices.

4. Low

   Summarizes the low-risk category using broad clinical examples and general procedure and management groupings.

5. Moderate

   Summarizes the moderate-risk category and the kinds of encounters, procedures, and management options associated with it.

6. High

   Summarizes the highest risk category and the broad types of serious problems, procedures, and treatment decisions included in the table.