Auditing: Weigh Surgical Risk to Select Correct E/M Level

Article Overview

This article is a coding and auditing overview for clinicians, coders, and compliance staff who review evaluation and management services tied to surgical cases. It focuses on how general surgical risk categories, patient-specific risk factors, and the urgency of surgery can influence the risk component of medical decision making. The discussion is framed around identifying when encounters may be considered moderate or high risk, and why accurate risk assessment matters in E/M level selection.