Along with history and physical examination, the complexity of medical decision making is the third key component for documentation and coding of evaluation and management (E/M) services. Current Procedural Terminology (CPT-4®) identifies four types of complexity in medical decision making: high, moderate, low and straightforward. Each type is defined by meeting or exceeding the minimum requirements for two of three elements (see Table 1):
- number of diagnoses or management options,
- amount and/or complexity of data to be reviewed and
- risk of complications, morbidity and/or mortality.
In this month's column, we'll focus on quantifying the amount and complexity of data, like medical records, diagnostic tests and other information, that must be obtained, reviewed and analyzed. Data review complexity is classified as minimal, limited, moderate or extensive (see Table 1) , but how does one determine which of these applies in any particular case?
The December 2010 Documentation Guidelines for Evaluation and Management (E/M) Services from the CMS Medical Learning Network (available online) does not give specific guidance on how much data review is required for each level of complexity, but does discuss at length what to consider and document in the medical record. In a nutshell, the decision is subjective and based on a clinician's judgment, but steps include:
- Personally reviewing and interpreting an image, tracing or specimen.
- Reviewing laboratory, radiology and/or other diagnostic test reports. A simple notation such as “WBC [white blood cell count] elevated” or “chest X-ray unremarkable” is acceptable. Alternatively, the review may be documented by initialing and dating the report that contains the test results.
- Discussing the results of laboratory, radiology or other diagnostic tests with the physician who performed or interpreted them.
- Discussing contradictory or unexpected test or procedure results with the physician who performed or interpreted the test or results.
- Deciding to obtain and review old medical records and/or obtain history from sources other than the patient.
- Reviewing old records and/or obtaining additional history from the family, caretaker or other source to supplement information obtained from the patient. A notation of “old records reviewed” or “additional history obtained from family” without elaboration is not sufficient.
To standardize criteria for the complexity of data review, the Marshfield Clinic in Marshfield, Wis., developed a scoring system in 1995 that has become a generally accepted industry standard. One to two points are assigned for each type of data review or related activity, as noted in Table 2. The points accumulated for the date of service are added to arrive at a total point score, as follows:
- 1 point is defined as “minimal” complexity
- 2 points is “limited” complexity
- 3 points is “moderate” complexity
- 4 or more points is “extensive” complexity
In summary, document data review and analysis thoroughly, including any independent review of imaging, tracings or specimens. Indicate which diagnostic tests are being ordered. Identify and interpret results of reports. Record discussions with other clinicians and the results of those discussions. Indicate which medical records were reviewed and the pertinent information gleaned from them. Determine the complexity of data review for each encounter using a point score if necessary.