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Department of Neurology
 

NEUROLOGY: CODING AND DOCUMENTATION:

Determination of the Level of Risk
The level of risk is key in determining the level of medical decision making. The level is determined as high, moderate, low or minimal, based on the risk of:
 

● significant complications

● morbidity and/or mortality

● co-morbidities, associated with the patient's presenting problem(s),

● diagnostic procedure(s)

● possible management options

Examples of presenting problems, diagnostic procedures and management option for high, moderate and low risk levels follow below. The risk is determined by: any item in the high category is HIGH RISK; no items in the high category and any item in the moderate category is MODERATE RISK; no items in either the high or moderate categories and any item in the low category is LOW RISK; no items in either the high, moderate or low categories and any item in the minimal category is MINIMAL RISK.
HIGH Presenting Problem • Any abrupt change in neurologic status

• ≥ 1 chronic illnesses with severe exacerbation, progression or side effect of Rx

• Decision for DNR or de-escalate care because of poor prognosis
Diagnostic Procedures • Angiogram

• Myelogram
Management Options • Drug therapy that requires monitoring for toxicity

• Parenteral controlled substances

• Elective major surgery with risk factors

• Any emergency surgery
 
MODERATE Presenting Problem • Undiagnosed new problem with uncertain prognosis

• ≥ 1chronic illnesses with mild exacerbation, progression or side effect of Rx

• Two or more stable chronic illnesses
 
Diagnostic Procedures • Lumbar puncture

• EMG

 

• CT / MRI (with contrast)

• Autonomic Studies
Management Options • Prescription drug therapy

• IV fluids with additives

• Elective major surgery with no risk factors
 
LOW Presenting Problem • One stable chronic illness
Diagnostic Procedures • CT / MRI (no contrast)

• EEG
Management Options • PT, OT

• OTC drugs
 
MINIMAL Presenting Problem • One self limited or minor problem
Diagnostic Procedures • Blood test

• Chest XR

• Ultrasound
Management Options • Rest

• Bandage

Examples
 

•  A patient with seen with new numbness of the hand (High Risk - acute change in neurologic status)

•  A patient with a known seizure history is changed from dilantin to tegretol (High Risk - prescription drug therapy that requires monitoring for toxicity)

•  A patient is seen in routine follow-up for a stable peripheral neuropathy and carpal tunnel syndrome (Moderate Risk - Two or more stable chronic illnesses)