The easiest column, most often left on the table
Risk is driven mainly by what you decide and prescribe, which makes it the simplest of the three elements to support and the one providers most often forget. Prescription medication management alone reaches moderate risk.
- Risk is set mostly by your plan: what you prescribe, monitor, or decide.
- Prescription drug management reaches moderate risk on its own.
- Surgical decisions and serious comorbidities push risk higher; document the reasoning.
This is the third of the three MDM columns, and it is often the easiest to support when the others fall short, because the risk rubric captures clinical complexity that every clinician already understands. It asks how risky your plan was, which in practice usually means what you prescribed or decided. The overview of medical decision making shows how this column fits with the other two.
The Four Levels of Risk
- Minimal: over-the-counter drugs; rest or other supportive care.
- Low: minor surgery with no identified risk factors; managing an over-the-counter medication.
- Moderate: prescription drug management; a decision about minor surgery with identified patient or procedure risk factors; a decision about elective major surgery without identified risk factors; a diagnosis or treatment significantly limited by social determinants of health.
- High: drug therapy requiring intensive monitoring for toxicity, such as anticoagulants or immunosuppressants; a decision about elective major surgery with identified risk factors; a decision about emergency major surgery; a decision about hospitalization; a decision not to resuscitate or to de-escalate care because of poor prognosis.
Prescription Drug Management and the Over-the-Counter Trap
In the risk column, managing a prescription medication supports moderate risk, which is what drives a level 4 visit (99214 or 99204). Management is broad: starting a new prescription, refilling one, increasing or decreasing a dose, discontinuing one, or continuing a medication with documented clinical reasoning all qualify. For most clinicians this is the single most common path to a properly coded level 4, because so many visits involve a prescription decision.
One trap deserves emphasis, because auditors look for it. Writing an over-the-counter medication on a prescription pad does not turn it into prescription drug management. An over-the-counter drug is, by definition, a non-prescription drug, and recommending one supports low risk (a level 3), not moderate. The one exception is when you prescribe a strength higher than what is available over the counter, which is then genuinely a prescription. Keep the distinction clean: a true prescription medication supports level 4; an over-the-counter recommendation supports level 3, even if you wrote it on a prescription.
A reminder on how the table works, so this is used correctly: risk is one of the three MDM elements, and a level 4 needs two of the three at the moderate level. In practice, a prescription decision paired with the problem being addressed usually gets you there, but the level rests on the combination, not on the prescription alone.
What Minor and Major Surgery Mean for Risk
The practical takeaway for proceduralists is that the decision itself carries risk credit, separate from performing the procedure. Counseling a patient about a major surgery, weighing its risks against the alternatives, and documenting that discussion carries risk credit even at the visit where you only decided, not operated: moderate risk for an elective major surgery without identified risk factors, and high risk when the patient has significant comorbidities or the surgery is urgent.
The Two Risk Situations Clinicians Forget
Beyond drugs and surgery, two situations are easy to miss. The first is a decision about hospitalization, including the decision to admit or to send home a patient who could reasonably have been admitted; weighing that choice is high risk. The second is a diagnosis or treatment significantly limited by social determinants of health, for example when a patient cannot afford a medication or lacks the housing or transportation to follow a plan safely; that is moderate risk. When either genuinely shapes your management, document it, because it raises the risk tier and, more to the point, it is part of the real clinical picture.
What to Write for the Risk Column
Reflect the risk in your plan, and say enough to show which level applies. "Continuing metformin 1000 mg twice daily; will monitor renal function given mild chronic kidney disease and recheck a basic metabolic panel in three months" makes routine prescription management visible, which is moderate risk. Naming the specific drug, the dose, and why you are monitoring is what makes the risk level legible to anyone reading the note. For procedures, name the procedure, its global period when relevant, and any patient factors that raise the risk.
Sources and Further Reading for This Chapter
- American Medical Association, Evaluation and Management (E/M) Coding. https://www.ama-assn.org/practice-management/cpt/evaluation-and-management-em-coding
- CMS, Physician Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician