In Medical Decision Making, “Risk” is often the trickiest element to apply correctly. Many clinicians instinctively focus on the severity of the patient’s condition—but per the AMA, that’s not the whole picture.
The level of risk refers to the risk of complications and/or morbidity or mortality of the patient management, not just the condition itself.
AMA’s Guidance on Risk
The level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment, and/or hospitalization. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management.
In other words:
- Risk ≠ how sick the patient is
- Risk = the potential consequences of the care you choose (or choose not) to provide
Let’s think about this:
Prescribing ibuprofen is often a low or minimal risk intervention—but not always.
For a healthy young adult with a minor ankle sprain, short-term ibuprofen may truly be minimal risk.
But in a 75-year-old patient with a history of peptic ulcer disease, chronic kidney disease, and heart failure, that same medication could significantly increase the risk of GI bleeding, renal injury, or fluid retention. In that case, the management risk may be moderate or even high, depending on the clinical circumstances.
The drug hasn’t changed—the patient’s individual risk profile has.
Common Examples in MDM Risk
- Moderate Risk: Initiating prescription drug therapy, deciding on elective surgery, or ordering advanced imaging with contrast
- High Risk: Decision for emergency major surgery, drug therapy requiring intensive monitoring for toxicity, or hospitalization due to acute change in condition
Common Misapplications
- Confusing condition severity with management risk
- Example: Stable angina might be moderate management risk if you’re starting a new prescription—high if patient is hospitalized for chest pain
- Overlooking “no action” as a risk decision
- Choosing not to pursue high-risk testing or treatment can still be high management risk if the stakes are significant
- Documenting only the plan, not the reasoning
- Without clinical rationale, the risk level may not be supported in coding review
Documentation Tips
- State why the plan carries risk (e.g., potential for complications, need for monitoring)
- Document both the condition and the management choice
- Include rationale for testing or treatment decisions—especially if deferring intervention
Why It Matters
Risk is one of the three pillars of MDM scoring. Misunderstanding or under-documenting it can downgrade complexity and reduce appropriate reimbursement. CMS, AAFP, AAPC, and AHIMA all emphasize: clear linkage between condition, management decision, and potential consequences is key.
Next in the Series
August 28 – Back to Basics: ROS and the Physical Exam
Sign up for our mailing list and follow along for more Back to Basics insights. http://eepurl.com/ihek1L