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

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