E/M Tool Usage: Medical Decision Making

Medical Decision Making Medical decision making refers to the level of complexity associated with establishing a diagnosis and/or selecting a management option. The level of complexity is measured by the following factors: **The number of possible diagnoses and/or the number of management options that must be considered by the examiner **The amount and complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed by the examiner **The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s) ordered, and/or the possible management options selected by the examiner.

A. Problem(s) Status	Points	Results
Self-limited or minor (stable, improved or worsening) (1 point)	Max=2
Est. problem (to examiner); stable, improved (1 point)	Max=2
Est. problem (to examiner); worsening (2 points)	Max=2
New problem (to examiner); no additional workup planned (3 points)	Max=1
New problem (to examiner); additional workup planned (4 points)	Max=1
Bring total to Line A in Final Result for Complexity Total :

B. Amount and/or Complexity of Data Reviewed

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

Review and/or order of clinical lab tests	1
Review and/or order of tests in the radiology section of CPT	1
Review and/or order of tests in the medicine section of CPT	1
Discussion of test results with performing physician	1
Decision to obtain old records and/or obtain history from someone other than the patient	1
Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider	2
Independent visualization of image, tracing or specimen itself (not simply review of report)	2
Bring total to line B in Final Result for Complexity Total :

C. Risk of Significant Complications, Morbidity, and/or Mortality

The risk of significant complications, morbidity, and/or mortality is based upon the risks associated with the presenting problem(s), the diagnostic procedure(s) ordered, and the management options selected. 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.

Level	Presenting Problem(s)	Diagnostic Procedure(s) Ordered	Management Options Selected
Minimal	One self-limited or minor problem	Lab tests requiring Venipuncture Chest or other diagnostic X-ray EKG/EEG Urinalysis Ultrasound KOH prep	Rest Gargles Elastic bandages Superficial dressings
Low	Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated illness or injury	Physiologic tests not under stress Non-cardiovascular imaging studies with contrast Superficial needle biopsies Clinical laboratory tests requiring Arterial puncture Skin biopsies	Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives
Moderate	One or more chronic illness with mild exacerbation or progression Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis Acute illness with systemic symptoms Acute complicated injury	Physiologic tests under stress Deep needle or incisional biopsy Diagnostic endoscopies with no identified risk factors Cardiovascular imaging studies with contrast and no identified risk factors Obtain fluid from body cavity	Minor surgery with identified risk factors Elective major surgery with no risk factors Prescriptions drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocations without manipulation
High	One or more chronic illness with severe exacerbation or progression Acute or chronic illness or injuries which pose a threat to life or bodily function Abrupt change in Neurologic status	Cardiovascular imaging studies with contrast with identified risk factors Cardiac Electrophysiological tests Diagnostic endoscopies with identified risk factors Discography	Elective major surgery with identified risk factors Emergency major surgery Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis

Now, add your numbers from above to get your medical decision making

A	Circle the number in section A	<1 Minimal	2 Limited	3 Multiple	4> Extensive
B	Circle the number in section B	<1 Minimal or none	2 Limited	3 Multiple	4> Extensive
C	Circle the number in section C	<1 Minimal	2 Low	Moderate	High
Complexity Level of Medical Decision Making		Straightforward SF	Low L	Moderate M	High H

Draw a line down the column with 2 or 3 circles and circle decision making level OR draw a line down the column with the center circle= level of MDM.

Time

If the physician documents total time and suggests that counselling or cordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential disgnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.

Documentation reveals total time? Time: Face to Face outpatient setting. Unit/Floor in inpatient setting	Yes	No
Documentation describes the content of counselling or coordinating care	Yes	No

If both answers are “Yes” you may select the level based on time.