decisionhealth Newsletters, Coder Pink Sheets - 2020 Issue 12 (December)
Understanding E/M: Investigate the new medical decision-making risk category
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Article Overview
This article reviews the revised risk component of E/M medical decision-making under the 2021 office visit guidelines. It is aimed at coders, auditors, and clinicians who need to understand how risk is assessed and documented across the recognized risk levels, including discussion of patient condition, testing or treatment considerations, and the role of social factors in documentation. The article also places the guidance in the context of the broader E/M framework and notes where related diagnosis coding concepts may appear.
Why This Topic Matters
Correctly understanding the risk element is important for accurate E/M level selection and compliant documentation under the 2021 guidelines. The topic affects how clinicians support visit complexity and how coding professionals evaluate the record.
What You Will Learn
- How the medical decision-making risk element fits into E/M visit selection
- How the 2021 guidance frames risk assessment and documentation
- How broad categories of risk are described in the updated table
- How social factors are discussed in relation to risk documentation
- How intensive monitoring is distinguished from more routine monitoring
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Other qualified health care professionals
- Practice managers
Code Ranges Discussed
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