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Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. For the most recent E/M coding guidance, visit our home page here.
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Low Risk |
This is the second lowest level of risk. Although marginally more serious than Minimal Risk encounters, Low Risk patients are generally quite healthy. Many physicians are surprised to learn that this is the level of risk required for the so-called “routine” level 3 office follow-up visit (99213).
This level of risk requires ONE element in ANY of the following three categories:
Presenting Problem(s)
- Two or more self-limited or minor problems
- One stable chronic illness
- Acute uncomplicated illness or injury (allergic rhinitis, ankle sprain, cystitis)
Diagnostic Procedure(s)
- Physiologic tests not under stress (e.g., PFTs)
- Non-cardiovascular imaging studies with contrast (e.g., barium enema)
- Superficial needle biopsies
- ABGs
- Skin biopsies
Management Options Selected
- Over-the-counter drugs
- Minor surgery with no identified risk factors
- Physical therapy
- Occupational therapy
- IV fluids without additives
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