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| Moderate Risk |
This is the second highest level of risk. However, a cursory review of the qualifications for this level of medical jeopardy reveals that these patients are usually not very sick. This is the level of risk required for a level 2 hospital progress note (99232) or a level 4 office follow-up visit (99214).
This level of risk requires ONE element in ANY of the following three categories:
Presenting Problem(s)
- One or more chronic illness with mild exacerbation or progression
- Two or more stable chronic illnesses
- Undiagnosed new problem with uncertain prognosis (e.g., lump in breast)
- Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis
- Acute complicated injury (e.g., head injury with brief loss of consciousness)
Diagnostic Procedure(s)
- Physiologic tests under stress (e.g., cardiac stress test)
- Diagnostic endoscopies with no identified risk factors
- Deep needle or incisional biopsies
- Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac catheterization)
- Obtain fluid from body cavity (e.g., LP, thoracentesis, culdocentesis)
Management Options Selected
- Minor surgery with identified risk factors
- Elective major surgery with no risk factors
- Prescriptions drug management
- Therapeutic nuclear medicine
- IV fluids with additives
- Closed treatment of fracture or dislocations without manipulation
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