E/M Coding Alert - 2024 Issue 1
Reader Question: Let Provider Dictate Risk
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Article Overview
This article addresses a practical E/M documentation question about how encounter risk is assessed for medical decision making. It explains the general framing used in CPT-related guidance, why the documenting clinician’s perspective matters, and the importance of capturing risk in a way that supports accurate code assignment. The piece is aimed at coders, auditors, and clinicians who work with E/M documentation.
Why This Topic Matters
Risk is a core element of E/M medical decision making, so understanding how it is documented affects coding accuracy and compliance. The article helps readers interpret broad guidance without overstepping into unsupported assumptions about risk level.
What You Will Learn
- How risk is discussed in the context of E/M medical decision making
- Why the documenting clinician’s assessment matters
- What general guidance says about documenting risk for code assignment
- How broad risk concepts are framed in CPT-related E/M guidance
Who Should Read This
- Medical coders
- Coding auditors
- Physicians and other qualified healthcare professionals
- Practice managers
- Compliance staff
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