A patient presents to the podiatrist for a diabetic foot examination. While the diabetes is not well controlled (ie, exacerbated), the foot examination is normal. There are no data points or treatment during this encounter. May this be considered as moderate risk under the MDM risk element based on the patients diabetes? The guidelines state that [t]rained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. If the physician states that this patient is at moderate risk of developing a diabetes-related condition, would this be considered as moderate risk? ...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article addresses how to think about risk within office visit medical decision making when a patient is seen for a diabetic foot examination and the diabetes is described as not well controlled. It is aimed at clinicians, coders, and auditors who need to interpret evaluation and management documentation using current risk concepts and supporting guidance from an E/M compendium. The discussion focuses on broad MDM risk principles, the role of documentation, and how the encounter context affects whether risk is considered elevated.

Why This Topic Matters

Accurate MDM risk assessment affects E/M coding support and audit defensibility. This topic is especially relevant when the documented diagnosis, examination findings, and encounter work do not all point in the same direction.

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