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PRESENTING PROBLEMS
AND RISK |
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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.
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Presenting Problems and Level of Risk
Minimal Risk
- One self-limited or minor problem (e.g., insect bite, cold)
Low Risk
- Two or more self-limited or minor problems
- One stable chronic illness
- Acute uncomplicated illness or injury (allergic rhinitis, ankle sprain, cystitis)
Moderate Risk
- 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)
High Risk
- One or more chronic illness with severe exacerbation or progression
- Acute or chronic illness or injuries which pose a threat to life or bodily function (e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure)
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