Amount and/or Complexity of Data to be Reviewed

The amount and/or complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. Indications of the amount and/or complexity of data being reviewed include:

** A decision to obtain and review old medical records and/or obtain 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 (indicates the complexity of data to be reviewed); and

** The physician who ordered a test personally reviews the image, tracing, or specimen to supplement information from the physician who prepared the test report or interpretation (indicates the complexity of data to be reviewed).



Some important points that should be kept in mind when documenting amount and/or complexity of data to be reviewed include:

** If a diagnostic service is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service should be documented.

** The review of laboratory, radiology, and/or other diagnostic tests should be documented. A simple notation such as “WBC 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.

** A decision to obtain old records or obtain additional history from the family, caretaker, or other source to supplement information obtained from the patient should be documented.

** Relevant findings from the review of old records and/or the receipt of additional history from the family, caretaker, or other source to supplement information obtained from the patient should be documented. If there is no relevant information beyond that already obtained, this fact should be documented. A  notation of “Old records reviewed” or “Additional history obtained from family” without elaboration is not sufficient.

** Discussion about results of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study should be documented.

** The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented.