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Documentation Guidelines for CPT Evaluation and Management Services                         

Determine the COMPLEXITY of MEDICAL DECISION MAKING


Level Decision # of Dx's/Mgt Options Amt/Complexity of Data Risk of Complications
1&2 Straightforward Minimal (1) Minimal or none (1) Minimal (1)
3 Low Complexity Limited (2) Limited (2) Low (2)
4 Moderate Complexity Multiple (3) Moderate (3) Moderate (3)
5 High Complexity Extensive (4+) Extensive (4+) High (4)

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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