Medical Decision-Making: Are you savvy on what constitutes a Low Level 3 for RISK?

Monday, May 22, 2023

With CMS’s ever-changing rules, it can be challenging for physicians and nurse practitioners to keep up with them all. Here’s a quick refresher on a topic we’ve been asked to address: What constitutes a Low Level 3 for Risk?

First, let’s review the guidelines from the American Medical Association (AMA):


  • 2 or more self-limited or minor problems
  • 1 stable, chronic illness
  • 1 acute, uncomplicated illness or injury
  • 1 stable, acute illness
  • 1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care
Limited (Must meet requirements of at least 1 out of 2 categories)
Category 1: Test and documents
Any combination of 2 from the following:


  • Review of prior external note(s) from each unique source
  • Review of the result(s) of each unique test
  • Ordering of each unique test

Category 2: Assessment requiring an independent historian(s)
(For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high)

Low risk of morbidity from additional diagnostic testing or treatment

Let’s break this down to make it less vague. What qualifies as “Low Risk”?

  • R.I.C.E therapy (rest, ice, compression, and elevation)
  • OTC medicines (even if a prescription is given): Sudafed, Motrin, Tylenol, Preparation H, Zyrtec, Vitamin B, D, and D3 are all examples of over-the-counter medications
  • Durable medical equipment (DME) supplies such as air casts, walking boots, casts, and crutches
  • Simple sutures (placement or removal)

What is NOT included in the “Low Risk” category? Last year’s guidelines allowed PT/OT (physical therapy/occupational therapy) or specialty referrals. However, these no longer count. When calculating, remember most of what you may have considered moderate-level risk factors are now categorized as low-level risk factors.

This is only one of the categories required to determine the level of E/M service based on medical decision-making. You now need 2 of the 3 categories to correctly determine the charge. The number and complexity of problems and the amount of data and tests ordered and reviewed must also be addressed. Even if it’s a complex issue, such as elevated HTN (hypertension), out-of-control diabetes, non-union fractures, or abnormal blood work requiring additional testing, medical decision-making needs to be addressed to help you select appropriate overall levels. Additionally, if only 2 tests are ordered without a documented reason or if there are more in-depth risk factors, it will result in a lower level.

Key to remember: If something is not specifically stated in the dictation, it did not happen. Please ensure all items addressed during the visit with your patient are documented so you can receive the appropriate credit.

Lastly, if you’re using ancillary staff to handle your billing, remember if the coding or practice staff cannot see something in your documentation, the insurance companies won’t be able to see it either.

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