DETERMINING THE OVERALL LEVEL OF MEDICAL DECISION MAKING

The overall level of decision making is decided by placing the level of each of the three components into the appropriate box in a manner that allows them to be summed up to rate the overall decision making as straightforward, low complexity, moderate complexity, or high complexity.

DOCUMENTATION

The use of templates, either preprinted forms or embedded in an electronic patient record (see Appendix H), is an efficient means of addressing the documentation of decision making. Rather than counting or scoring the elements of the three components and actually filling out a grid like the one in the Table , a template can be constructed in collaboration with the compliance officer of your practice or institution to include prompts that capture the required data necessary to document complexity. Solo practitioners may require the assistance of their specialty association or a consultant to develop appropriate templates

Remember: Clinically, there is a close relationship between the nature of the presenting problem and the complexity of medical decision making. For example:

• Patient A comes in for a prescription refill—straightforward decision making 

• Patient B presents with suicidal ideation—decision making of high complexity

Select the Appropriate Level of E/M Service

As noted earlier, each category of E/M service has three to five levels of work associated with it. Each level of work has a descriptor of the service and the required extent of the three key components of work. For example

99223

Descriptor: Initial hospital care, per day for the evaluation and management of a patient, which requires these three key components:

• A comprehensive history 

• A comprehensive examination 

• Medical decision making that is of high complexity

For new patients, the three key components (history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for each level of service for office visits, initial hospital care, office consultations, initial inpatient consultations, confirmatory consultations, emergency department services, comprehensive nursing facility assessments, domiciliary care, and home services.

For established patients, two of the three key components (history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for each level of service for office visits, subsequent hospital care, follow-up inpatient consultations, subsequent nursing facility care, domiciliary care, and home care.

WHEN COUNSELING AND COORDINATION OF CARE ACCOUNT FOR MORE THAN 50% OF THE FACE-TO-FACE PHYSICIAN–PATIENT ENCOUNTER 

When counseling and coordination of care account for more than 50% of the face-to-face physician–patient encounter, then time becomes the key or controlling factor in selecting the level of service. Note that counseling or coordination of care must be documented in the medical record. The definitions of counseling, coordination of care, and time follow

Counseling is a discussion with a patient or the patient’s family concerning one or more of the following issues:

• Diagnostic results, impressions, and/or recommended diagnostic studies 

• Prognosis 

• Risks and benefits of management (treatment) options 

• Instructions for management (treatment) and/or follow-up

• Importance of adherence to chosen management (treatment) options 

• Risk factor reduction 

• Patient and family education

Coordination of care is not specifically defined in the E/M section of the CPT manual. A working definition of the term could be as follows: Services provided by the physician responsible for the direct care of a patient when he or she coordinates or controls access to care or initiates or supervises other healthcare ser-vices needed by the patient. Outpatient coordination of care must be provided face-to-face with the patient. Coordination of care with other providers or agencies without the patient being present on that day is reported with the case management codes.