Straightforward

COPA (complexity of problems addressed)

• • 1 self-limited or minor problem

Data reviewed/analyzed

• • Minimal or none

Patient management

• • Minimal risk of complications

Low complexity

COPA (complexity of problems addressed)

• • 2 or more self-limited or minor problems

  • 1 stable chronic illness

  • 1 acute, uncomplicated illness or injury

  • 1 stable, acute illness

  • 1 acute, uncomplicated illness or injury requiring hospital inpatient or obs level of care

Data reviewed/analyzed (at least 1 of the 2 categories)

• • Category 1: Tests and documents; any combination of 2 from the following:

    1. Review of prior external note(s) from each unique source

    2. Review of the result(s) of each unique test

    3. Ordering of each unique test

  • Category 2: Assessment requiring an independent historian(s)

Patient management

• • low risk of complications

Moderate complexity

COPA (complexity of problems addressed)

• • 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment

  • 2 or more stable chronic illnesses

  • 1 undiagnosed new problem with uncertain prognosis

  • 1 acute illness with systemic symptoms

  • 1 acute complicated injury

Data reviewed/analyzed (at least 1 of the 3 categories)

• • Category 1: Tests, documents, or independent historian(s) (at least 3)

    1. Review of prior external note(s) from each unique source

    2. Review of the result(s) of each unique test

    3. Ordering of each unique test

    4. Assessment requiring an independent historian(s)

  • Category 2: Independent interpretation of tests

  • Category 3: Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source

Patient management

• • Category 1: Tests, documents, or independent historian(s) (at least 3)

    1. Review of prior external note(s) from each unique source

    2. Review of the result(s) of each unique test

    3. Ordering of each unique test

    4. Assessment requiring an independent historian(s)

  • Category 2: Independent interpretation of tests

  • Category 3: Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source

Orders labs/imaging

Review labs/imaging

Differential diagnoses

Outside records

Reassessment

Speaking to other medical providers

Document system of immediate threat to life or physiologic function

Document total time spent in direct care of patient

• Time must be at least 30 minutes

• Cannot include reportable procedures such as intubation or central line placement

• Time can include looking up charts or labs, and discussion with family or consultants