Documentation for the Complexity of Medical Decision Making
Documentation for the Complexity of Medical Decision Making
The levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity, and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the number of possible diagnoses and/or the number of management options that must be considered; the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options. The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.
| Number of diagnoses or management options | The amount and/or complexity of data to be reviewed | Risk of complications and/or morbidity or mortality | Type of decision making |
|
Minimal | Minimal or None | Minimal | Straightforward |
|
Limited | Limited | Low | Low Complexity |
| Multiple | Moderate | Moderate |
Moderate Complexity |
| Extensive | Extensive | High |
High Complexity |
Possible Diagnoses and/or Management Options
The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions that are made by the physician. Generally, decision-making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of the complexity of diagnostic or management problems.
The Complexity of Data to be Reviewed
The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. A decision to obtain and review old medical records and/or obtain a history from sources other than the patient increases the amount and complexity of data to be reviewed. Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test is an indication of the complexity of data being reviewed. On occasion the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or interpretation; this is another indication of the complexity of data being reviewed.
Correct documentation ensures timely payments, sometimes it becomes little complex as commercial and private payer has different documentation guidelines. E2E Medical Billing Services can assist you in the documentation process along with other medical billing operations. To know more about our billing and coding services call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com