appropriate. A notation of “Old records reviewed” or “Additional history obtained from family” without elaboration is not sufficient. Page 17 of 23 MLN006764 February 2021 Evaluation and Management Services Guide MLN Booklet ● Discussion about results of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study. ● The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician. Risk of Significant Complications, Morbidity, and/or Mortality The risk of significant complications, morbidity, and/or mortality is based on the risks associated with these categories: ● Presenting problem(s) ● Diagnostic procedure(s) ● Possible management options The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next encounter. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk. The level of risk of significant complications, morbidity, and/or mortality can be: ● Minimal ● Low ● Moderate ● High Here are some important points to keep in mind when documenting level of risk. You should document: ● Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality. ● The type of procedure, if a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter. ● The specific procedure, if a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter. ● The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis. This point may be implied. This table can help determine whether the level of risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. Evaluation and Management Services Guide MLN Booklet Page 18 of 23 MLN006764 February 2021 Table of Risk LEVEL OF RISK PRESENTING PROBLEM(S) DIAGNOSTIC PROCEDURE(S) ORDERED MANAGEMENT OPTIONS SELECTED Minimal ● One self-limited or minor problem (for example, cold, insect bite, tinea corporis) ● Laboratory tests requiring venipuncture ● Chest x-rays ● EKG/EEG ● Urinalysis ● Ultrasound (for example, echocardiography) ● KOH prep ● Rest ● Gargles ● Elastic bandages ● Superficial dressings Low ● Two or more selflimited or minor problems ● One stable chronic illness (for example, well controlled hypertension, noninsulin dependent diabetes, cataract, BPH) ● Acute uncomplicated illness or injury (for example, cystitis, allergic rhinitis, simple sprain) ● Physiologic tests not under stress (for example, pulmonary function tests) ● Non-cardiovascular imaging studies with contrast (for example, barium enema) ● Superficial needle biopsies ● Clinical laboratory tests requiring arterial puncture ● Skin biopsies ● Over-the-counter drugs ● Minor surgery with no identified risk factors ● Physical therapy ● Occupational therapy ● IV fluids without additives Table 5: Table of Risk Page 19 of 23 MLN006764 February 2021 Evaluation and Management Services Guide MLN Booklet LEVEL OF RISK PRESENTING PROBLEM(S) DIAGNOSTIC PROCEDURE(S) ORDERED MANAGEMENT OPTIONS SELECTED Moderate ● One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment ● Two or more stable chronic illnesses ● Undiagnosed new problem with uncertain prognosis (for example, lump in breast) ● Acute illness with systemic symptoms (for example, pyelonephritis, pneumonitis, colitis) ● Acute complicated injury (for example, head injury with brief loss of consciousness) ● Physiologic tests under stress (for example, cardiac stress test, fetal contraction stress test) ● Diagnostic endoscopies with no identified risk factors ● Deep needle or incisional biopsy ● Cardiovascular imaging studies with contrast and no identified risk factors (for example, arteriogram, cardiac catheterization) ● Obtain fluid from body cavity (for example, lumbar puncture, thoracentesis, culdocentesis) ● Minor surgery with identified risk factors ● Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors ● Prescription drug management ● Therapeutic nuclear medicine ● IV fluids with additives ● Closed treatment of fracture or dislocation without manipulation Table 5 (cont.): Table of Risk Evaluation and Management Services Guide MLN Booklet Page 20 of 23 MLN006764 February 2021 LEVEL OF RISK PRESENTING PROBLEM(S) DIAGNOSTIC PROCEDURE(S) ORDERED MANAGEMENT OPTIONS SELECTED High ● One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment ● Acute or chronic illnesses or injuries that pose a threat to life or bodily function (for example, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis,