||# of Dx's/Mgt Options
||Amt/Complexity of Data
||Risk of Complications
||Minimal or none (1)
Decision Making (2 of 3 required)
A. Number of diagnoses or management options: clinical impressions, referrals, changes in treatment.
B. Amount and/or complexity of data to be reviewed: test and procedures ordered, reviewed, and /or discussed as well as old records reviewed.
C. Risk of complexity/morbidity/mortality.
1. Dx and Management Options
Self-limiting/minor problem, stable, improved, worsening (pt.) max = 2
Established problem, stable, improved well controlled/resolving or resolved (1 pt.)
Established problem, worsening, failing to respond, inadequately controlled (2 pts.)
New Problem, no additional workup planned (3 pts.) max = 1
New problem with additional workup planned (4 pts.)
TOTAL = _______
2. Amount and /or Complexity of Data
Discuss tests with performing physician (1 pt.)
Ordered/reviewed labs/x-rays/tests from medicine section of CPT (1 pt.)
Decision to obtain old records/hx from someone other than the patient (1 pt.)
Independent review of tracings, specimens or x-rays (2 pts.)
Review/summarize old records /hx from someone other than the patient (2 pts.)
TOTAL = ________
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