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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. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.


Diagnostic Procedures and Level of Risk

Minimal Risk

  • Lab tests
  • Chest X-ray
  • Urinalysis
  • Ultrasound/Echocardiography
  • KOH prep
Low Risk
  • Physiologic tests not under stress (e.g., PFTs)
  • Non-cardiovascular imaging studies with contrast (e.g., barium enema)
  • Superficial needle biopsies
  • ABGs
  • Skin biopsies
Moderate Risk
  • 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)
High Risk
  • Cardiovascular imaging studies with contrast with identified risk factors
  • Cardiac EP testing
  • Diagnostic endoscopies with identified risk factors
  • Discography
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