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

Why This Topic Matters

Correctly recognizing surgical risk categories can affect E/M level selection and reduce the chance of undercoding or overcoding surgical encounters. The article is relevant to anyone auditing or documenting surgical cases where risk level is part of medical decision making.

Article Sections

1. Emergency Surgery Requires Immediate Performance

   This section describes the broad characteristics of emergency surgery and why it is treated as higher risk in the context of surgical management. It also notes examples of procedure types discussed in the article.

2. Risk Factors Apply to Individual

   This section explains that risk factor assessment depends on patient-specific comorbidities and other factors affecting surgery, healing, and anesthesia. It contrasts planned surgery without identified risk factors with surgery where additional clinical risks are present.