Risky Business


We love to talk about risk at PCR.

Love it.


We love to look at patient encounters in terms of risk, and we think you should to. There is a lot going on during a patient visit, but one thing that is for sure happening is the transfer of risk from the patient to provider. A patient arrives at your practice with a chief complaint. You listen, ask questions, order tests, evaluate and then manage the patient. During all of this you are taking on risk. It’s on you to get the diagnosis right, not miss any red flags and make sure that the treatment plan is safe and appropriate for the patient.


There are then only two ways for you to then transfer the risk. One way is by carrying malpractice insurance. And the second is by charging more for the riskier patients and procedures. Why does a 2.5 cm laceration pay more than a 1 cm laceration? Increased risk. Why does removing a foreign body that requires an incision pay more than removing one without? Risk.


The same goes for different types of patients you see in the clinic. Different patients present different levels of risk simply by the nature of their complaint. We understand this from an academic level, but we rarely think about it from a documentation level. And this is where many of us are making mistakes and not being properly compensated for the risks we take seeing patients. But here at Physician Coding Resource its where we want you to start when it comes to determining a level of service for a patient.


The 1995 Medicare guidelines gives you a table of risk. This table gives examples of presenting problems and whether they are high, moderate, low or minimal risk. High risk is correlated with a level 5 patient. Moderate risk is typically associated with a level 4 patient and low risk is typically associated with a level 3 patient. This isn’t always the case but for most of your patient encounters it will hold true. You can see the original table of risk here in this pdf from CMS but I have inserted it below.





What I want you to focus on is in the first column under “Presenting Problems”. You will see several different examples in this column but look initially at those next to the moderate risk section. These are some examples of presenting problems that are typically associated with moderate risk, or level 4 patients. They include:


One or more chronic illness with a mild exacerbationAcute illness with systemic symptomsTwo or more stable chronic problems


Now, I don’t know about you, but I see these types of patients nearly every day. Nearly every visit. And CMS tells us that these patients are moderate risk and that moderate risk usually correlates with level 4 patients. That means that most likely most patients that come to see you should be level 4 visits.


Look at your billing and coding and see what your levels look like. If you need to learn medical billing and coding, we can help. Also, look at the 1995 guidelines and their table of risk. You see a ton of level 4 patients. You are seeing risky patients. You need to be compensated for it. And the only way to do this is by properly documenting for coding purposes. We want you to be properly compensated for the risk you take seeing patients and we can teach you how.

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