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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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