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.
