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  • E/M Medical Decision-Making When Prescribing High-Risk Medication

    When I prescribe steroid drops for an acute eye condition does this increase my evaluation and management (E/M level) because steroids are higher-risk medications?

    “High risk” in E/M medical decision making (MDM) is drug therapy requiring intensive monitoring for toxicity. This means long-term monitoring occurring no less than quarterly, performed by labs or imaging and not by history of examination. Short-term steroid use for acute illness does not meet this level of risk.

    Determining the final level of E/M requires that two of three components (problem, data, and risk) meet the same level of complexity. For MDM, risk level is based on morbidity of the problem(s) addressed at the encounter when appropriately treated.

    Academy education resources on E/M medical decision making can be found at