Documenting Risk in 2023 Shannon DeConda

As we begin the new year and our focused training for the 2023 E&M changes and revisions, I'd like to encourage everyone to refocus their efforts on column three of medical decision-making. Most of the documentation that we've seen so far utilizing 2021 documentation guidelines has continued to rely on documentation of merely managing the patient as opposed to the risks of managing that patient. How do we document for this shift? In this "Today's Take" we'll discuss what this Column really says - and what our providers should really be documenting in 2023.
Leave your comments below and be sure to subscribe! If I can be of help to you or your organization, reach out to [e-mail]. You can also read my blog post on this topic at namas.co/z3ttz. You can find more tools and resources for the expansion to the 2021 E&M guidelines at www.namas.co/2021-changes.

[@mariasantiago7510]

Thank you Shannon, this is what I have been trying to say to fellow auditors in my group as well. The full title of that column says...The risk of AND/OR I agree with you also, documentation is key, because if extensive evaluation may be required to reach the conclusion that the signs or symptoms or multiple conditions in aggregate may represent a highly morbid condition (due to interaction) it should be clearly captured in documentation and considered under column 3 (Risk). Also, if you do a search of the definitions, risk of morbidity is described for almost every problem defined (i.e., under Stable, chronic illness: A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function...the risk of morbidity without treatment is significant). This is described in almost every definition. Yes, risk of condition is distinct from risk of complication/management but the guidelines make clear that these often times correlate.~

[@deneenheino8094]

Is it possible to dive deeper into the risk of management, maybe some scenarios. I'm having a hard time understanding what should be represented in documentation. Thanks

[@KarenWatson-ni3bj]

Thank you Shannon is there any education for sale with examples

[@madison1ification]

I code for cardiology and and they frequently manage patients in the hospital with inotropes and vasodilators. These patients are in cardiogenic shock. It would seem the risk of morbidity or mortality would warrant HIGH RISK. As if they weren’t making those decisions the patient would most likely die? Would this be true?

[@mdimamhasan5201]

Sounds good!