Medical decision making for E/M services

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.
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In this month's column, we'll focus on the third element: the risk of complications, morbidity and/or mortality, which is a highly subjective, complex determination. Risk is classified as minimal, low, moderate or high. Classification is based on the highest level of risk on the date of service in any one of the following three categories:

  • Presenting problems—the expected risk between the current and next encounters associated with the number and severity of current, active diagnoses and conditions (e.g., cellulitis, ruptured appendix, syncope, hypovolemic shock).
  • Diagnostic procedures—risks immediately before and after the procedure (e.g., CT angiogram, arterial blood gas, thoracentesis, cardiac catheterization).
  • Management/treatment options—risks associated with a therapeutic procedure or other treatment on the date of service (e.g. chemotherapy, coronary artery bypass graft, patient-controlled analgesia pump, radiation therapy).

The only specific guidance in assigning level of risk is the so-called “Table of Risk” (see Table 2) found in the “Documentation Guidelines for Evaluation and Management (E/M) Services” from the Centers for Medicare and Medicaid Services' Medical Learning Network. This table provides examples to assist physicians in the assignment of risk but requires clinical judgment and interpretation for application. The Marshfield scoring system does not provide additional assistance with risk assignment, simply referring to the Table of Risk.

In summary, become familiar with the Table of Risk to guide your risk assessment. On each date of service, document the current diagnoses and conditions being actively managed, diagnostic procedures, and therapeutic procedures and other management/treatment provided to indicate the associated risks. Remember that the highest level of risk associated with any one of these three categories determines risk for the encounter on that date of service.