Decision Making

Documentation required for the complexity of medical decision making is divided into three areas according to the guidelines. These three areas are:

• Number of diagnoses or management options
  
• Amount and/or complexity of data to be reviewed
  
• Risk of complications and/or morbidity or mortality
  

Only 2 of these 3 areas must be met.

These criteria will separate all patients into one of the following four areas:

• Straightforward decision
  
• Low complexity
  
• Moderate complexity
  
• High complexity
  

The following table summarizes the criteria needed for each of these four areas:

# Of DX or Management Options	Amount and/or Complexity of Data	Risk of Complications	Type of Desicion	E & M Billing Code
Minimal 1	Minimal or None	Minimal One self-limited minor problem	Straightforward	New: 99201 & 99202 or Established: 99212
Limited 2 to 3	Limited	Limited 1. Two self-limited minor problems 2. One stable chronic illness or 3. One acute uncomplicated illness or injury	Low complexity	New: 99203 or Established: 99213
Multiple 4 to 7	Moderate	Multiple 1. Chronic Illness with mild exacerbation 2. Two stable chronic illnessess 3. Undiagnosed new problem with uncertain prognosis 4. Acute illness with systemic sx's or acute complicated injury	Moderate complexity	New: 99204 or Established: 99212
Extensive 8 or more	Extensive	High 1. Chronic Illness with severe exacerbation 2. Acute or chronic illnessess that pose a threat to life or bodily function 3. An abrupt change in neurologic status	High complexity	New: 99205 or Established: 99215

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