April 21, 2021
E & M Documentation Education: Risk
Evaluation and Management (E&M) for the ambulatory environment underwent a major overhaul in 2021. We know this is a major adjustment at a time when there is already too much upheaval. We are committed to supporting you with the information you need, in different mediums (written, visual, podcast, and full presentation), in different levels of intensity and time commitment, and with content that will evolve as we learn together.
Risk did not change at all in the new paradigm. However, most providers don’t have the habit of explicitly stating risk. This means that you are likely doing complex cognitive work for which you are not getting credit. A very common opportunity is to more clearly articulate clinical perception of risk. Risk is difficult for coders to score objectively; coders are relying on a table that cannot possibly replace the medical complexity a provider perceives. Check out our brief slide deck on risk, listen to our brief podcast on risk (coming soon), or print out one page cheat-sheet handout on risk.
Many simple reference handouts have been created trying to get you the information you need at your finger tips when you need to reference it in your busy day. The MASTER handout is E&M Documentation Guidelines and Definitions for 99202—99215. Keep this one handy and check out the additional one-page items for helpful information.