Medical Decision-Making Component

Published 08/03/2020

The levels of evaluation and management (E/M) services recognize four types of medical decision-making (straightforward, low complexity, moderate complexity and high complexity). Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

  • Number of possible diagnoses and/or the number of management options that must be considered
  • Amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed and analyzed
  • Risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options

The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.

Presenting Problems
1=Minimal
2=Limited
3=Multiple
4= Extensive
Diagnostic Procedures
1=Minimal
2=Limited
3=Multiple
4= Extensive
Management Options
1=Minimal
2=Limited
3=Multiple
4= Extensive
Overall Risk
Straightforward Complexity
Low Complexity
Moderate Complexity
High Complexity

Each of the elements of medical decision-making is described below.

Number of Diagnoses or Management Options
The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.

Generally, decision-making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems.

Documentation Reminders and Frequently Asked Questions

  • For each encounter, an assessment, clinical impression or diagnosis should be documented which may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation:
    • For a presenting problem with an established diagnosis, the record should reflect whether the problem is:
      • Improved, well controlled, resolving or resolved; or
      • Inadequately controlled, worsening or failing to change as expected
    • For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a "possible," "probable" or "rule out" diagnosis
  • The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies and medications
  • If referrals are made, consultations requested or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom advice is requested
  • In most instances, a new problem is one that is new to the provider and being addressed at that visit. There are two exceptions to this general rule:
    • The initial visit of an established beneficiary in a single specialty group practice setting with a new provider
    • A visit by an "on call" or covering provider. In these instances, the established problems are treated as if the beneficiary was seen by the unavailable provider.  

Amount and/or Complexity of Data to Be Reviewed
The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. 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 is an indication of the complexity of data being reviewed. On occasion, the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or interpretation; this is another indication of the complexity of data being reviewed.

Documentation Reminders and Frequently Asked Questions

  • 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
  • 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
    • The documentation must clearly reflect the provider "independently" reviewed the image, tracing or specimen
  • 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.

Risk of Significant Complications, Morbidity and/or Mortality
The risk of significant complications, morbidity and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s) and the possible management options.

The table below may be used to help determine whether the risk of significant complications, morbidity and/or mortality is minimal, low, moderate or high.

Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s) or management options) determines the overall risk.

Level of RiskPresenting ProblemDiagnostic ProceduresOrdered Management Options Selected

Minimal

 One self-limited or minor problem, (e.g., cold, insect bite, tinea corporis)
  • Laboratory tests requiring venipuncture
  • Chest X-rays
  • EKG/EEG
  • Urinalysis
  • Ultrasound, (e.g., echocardiography)
  • KOH prep
  • Rest
  • Gargles
  • Elastic bandages
  • Superficial dressings

Low

Two or more self-limited or minor problems

One stable chronic illness, (e.g., well controlled hypertension, non-insulin dependent diabetes, cataract, BPH)

Acute uncomplicated illness or injury, (e.g., cystitis, allergic rhinitis, simple sprain)

  • Physiologic tests not under stress, (e.g., pulmonary function tests)
  • Non-cardiovascular imaging studies with contrast, (e.g., barium enema)
  • Superficial needle biopsies
  • Clinical laboratory tests requiring arterial puncture
  • Skin biopsies
  • Occupational therapy
  • IV fluids without additives
  • Over-the-counter drugs
  • Minor surgery with no identified risk factors
  • Physical therapy
Moderate One or more chronic illnesses with mild exacerbation, progression or side effects of treatment

Two or more stable chronic illnesses

Undiagnosed new problem with uncertain prognosis, (e.g., lump in breast)

Acute illness with systemic symptoms, (e.g., pyelonephritis, pneumonitis, colitis)

Acute complicated injury, (e.g., head injury with brief loss of consciousness)
  • Physiologic tests under stress, (e.g., cardiac stress test, fetal contraction stress test)
  • Diagnostic endoscopies with no identified risk factors
  • Deep needle or incisional biopsy
  • Cardiovascular imaging studies with contrast and no identified risk factors, (e.g., arteriogram, cardiac catheterization)
  • Obtain fluid from body cavity, (e.g.: lumbar puncture, thoracentesis, culdocentesis)
  • Minor surgery with identified risk factors
  • Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors
  • Prescription drug management
  • Therapeutic nuclear medicine
  • IV fluids with additives
  • Closed treatment of fracture or dislocation without manipulation
High One or more chronic illnesses with severe exacerbation, progression or side effects of treatment

Acute or chronic illnesses or injuries that pose a threat to life or bodily function, (e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure)

An abrupt change in neurologic status, (e.g., seizure, TIA, weakness, sensory loss)  
  • Cardiovascular imaging studies with contrast with identified risk factors
  • Cardiac electrophysiological test
  • Diagnostic Endoscopies with identified risk factors
  • Discography
  • Elective major surgery
    (open, percutaneous or endoscopic) with identified risk factors
  • Emergency major surgery (open, percutaneous or endoscopic)
  • Parenteral controlled substances
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision not to resuscitate or to de-escalate care because of poor prognosis

Example
Patient is seen in the office for:

  • Hypertension, stable, continue on Lisinopril 10mg
  • Stable, diet controlled DM2 (HGBa1c 6.2)

Presenting Problems
1=Minimal
2=Limited
3=Multiple
4= Extensive
Diagnostic Procedures
1=Minimal
2=Limited
3=Multiple
4= Extensive
Management Options
1=Minimal
2=Limited
3=Multiple
4= Extensive
Overall Risk
Straightforward Complexity
Low Complexity
Moderate Complexity
High Complexity

Documentation Reminders and Frequently Asked Questions

  • Comorbidities/underlying diseases or other factors that increase the complexity of medical decision-making by increasing the risk of complications, morbidity and/or mortality should be documented
  • If a surgical or invasive diagnostic procedure is ordered, planned or scheduled at the time of the E/M encounter, the type of procedure should be documented
  • If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented; and
  • The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied
  • An article has been published on the Palmetto GBA website and can be located under the "E/M Help Center." This article contains a definition and description of "Drugs Requiring Intense Monitoring" along with a list of drugs that would meet the criteria.

Resource: Documentation Guidelines for Evaluation and Management (E/M) Services.

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