asymptomatic organ system(s). Table 3: Single Organ System Examination Page 15 of 23 MLN006764 February 2021 Evaluation and Management Services Guide MLN Booklet Medical Decision Making Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering these factors: ● The number of possible diagnoses and/or the number of management options that must be considered ● The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed ● 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), and/or the possible management options This table shows the progression of the elements required for each level of medical decision making. Note that to qualify for a given type of medical decision making, two of the three elements must either be met or exceeded. Elements for Each Level of Medical Decision Making TYPE OF DECISION MAKING NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS AMOUNT AND/ OR COMPLEXITY OF DATA TO BE REVIEWED RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY Straightforward Minimal Minimal or None Minimal Low Complexity Limited Limited Low Moderate Complexity Multiple Moderate Moderate High Complexity Extensive Extensive High Number of Diagnoses and/or Management Options The number of possible diagnoses and/or the number of management options to consider is based on: ● The number and types of problems addressed during the encounter ● The complexity of establishing a diagnosis ● The management decisions made by the physician In general, decision making for a diagnosed problem is easier than decision making for an identified but undiagnosed problem. The number and type of diagnosed tests performed may be an indicator of the number of possible diagnoses. Problems that are improving or resolving are less complex than those problems that are worsening or failing to change as expected. Another indicator of the complexity of diagnostic or management problems is the need to seek advice from other health care professionals. Table 4: Elements for Each Level of Medical Decision Making Evaluation and Management Services Guide MLN Booklet Page 16 of 23 MLN006764 February 2021 Here are some important points to keep in mind when documenting the number of diagnoses or management options. You should document: ● An assessment, clinical impression, or diagnosis for each encounter, which may be explicitly stated or implied in documented decisions for management plans and/or further evaluation: • For a presenting problem with an established diagnosis, the record should reflect whether the problem is: ◦ Improved, well controlled, resolving, or resolved ◦ Inadequately controlled, worsening, or failing to change as expected • For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis ● The initiation of, or changes in, treatment, which includes a wide range of management options such as patient instructions, nursing instructions, therapies, and medications ● If referrals are made, consultations requested, or advice sought, to whom or where the referral or consultation is made or from whom advice is requested Amount and/or Complexity of Data to Be Reviewed The amount and/or complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. Indications of the amount and/or complexity of data being reviewed include: ● A decision to obtain and review old medical records and/or obtain history from sources other than the patient (increases the amount and complexity of data to be reviewed) ● Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test (indicates the complexity of data to be reviewed) ● The physician who ordered a test personally reviews the image, tracing, or specimen to supplement information from the physician who prepared the test report or interpretation (indicates the complexity of data to be reviewed) Here are some important points to keep in mind when documenting amount and/or complexity of data to be reviewed. You should document: ● The type of service, if a diagnostic service is ordered, planned, scheduled, or performed at the time of the E/M encounter. ● The review of laboratory, radiology, and/or other diagnostic tests. A simple notation such as “WBC elevated” or “Chest x-ray unremarkable” is acceptable. Alternatively, document the review by initialing and dating the report that contains the test results. ● A decision to obtain old records or additional history from the family, caretaker, or other source to supplement information obtained from the patient. ● Relevant findings from the review of old records and/or the receipt of additional history from the family, caretaker, or other source to supplement information obtained from the patient. You should document that there is no relevant information beyond that already obtained, as