Documentation of

Medical Decision
Making

Created by The Lung Doctor for e-Medtools

Elements of Medical Decision Making
• Number of diagnoses or Management Options
• Amount or Complexity of data to be reviewed
• Risk of Complications, Morbidity or Mortality

Created by The Lung Doctor for e-Medtools

 Complexity of Medical Decision Making
Number of Amount or Risk of Complexity of
Diagnoses Complexity of Data Complications Decision Making
Or Management to be Reviewed Morbidity or
Options Mortality
Minimal Minimal or None Minimal Straightforward
Limited Limited Low Low
Multiple Moderate Moderate Moderate
Extensive Extensive High High
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Created by The Lung Doctor for e-Medtools

 Worksheets
Calculating Documentation Levels
Adaptedfrom
Adapted from
HGSAdministratorsDocumentation
HGSAdministrators DocumentationWorksheet
Worksheet
CMSMedicare
MedicarePart
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Created by The Lung Doctor for e-Medtools

 History
HPI: Status of chronic conditions □ □
1-2 3
□1 condition □2 conditions □3 conditions

HPI elements □ □
□Location □Severity □Timing □Modifying factors Brief Extended
1-3 4 or more
□Quality □Duration □Context □Associated signs & symptoms
Review of Systems □ □ □ □
□Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes None Pertinent to Extended Complete
Problem 2-9
□CV □MS □Neuro □Aller/Immun □Resp □Psych 1 system Systems
10 or more
Systems
□All others negative
PFSH □ □ □
□Past History □Family History □Social History None Pertinent Complete
1 2 or 3
Problem Expanded Detailed Comprehensive
Focused Problem
Focused

Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted

Created by The Lung Doctor for e-Medtools

 Examination
Body Areas □ □ □ □
□Head, Face □Chest, Breasts, Axilla 1 Up to 7 Up to 7 8 or more
Body Area Body Areas Body Body Areas
□Abdomen □Neck □Back, Spine or or Areas or
□Genitalia, Groin, Buttocks □Each Extremity System Systems or Systems
Systems
Organ Systems
□Constitutional □ENT □Resp □MS □GI □Skin
□GU □Psych □CV □Eyes □Heme/Lymph □Neuro
Problem Expanded Detailed Comprehensive
Focused Problem
Focused
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted

Created by The Lung Doctor for e-Medtools

 Medical Decision Making
Reminder:
There are 3 components used to determine the complexity of medical decision making
• Number of diagnoses or Management Options
• Amount or Complexity of data to be reviewed
• Risk of Complications, Morbidity or Mortality

Created by The Lung Doctor for e-Medtools

 Number of Diagnoses or Treatment Options
Complexity of Medical Decision Making
A B x C = D
Problem status Number Points Result
Self-limited or minor Max = 2 1
Established problem (to examiner) 1
Stable or improved

Established problem (to examiner) 2

Worsening

New problem (to examiner) Max = 1 3

No additional workup planned

New problem (to examiner) 4

Additional workup planned

Total
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted
Created by The Lung Doctor for e-Medtools
 Amount and/or Complexity of Data Reviewed
Complexity of Medical Decision Making
Reviewed Data Points Result
Clinical lab tests reviewed and/or ordered
1
Review and/or order of tests from radiology section of CPT
1
Review and/or order of tests from medicine section of CPT
1
Discussion of test results with performing physician
1
Decision to obtain history from source other than patient
1
Review and summarization of history obtained from source other than patient
2
Independent visualization of image, tracing or specimen (NOT reviewing report)
2
TOTAL
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted

Created by The Lung Doctor for e-Medtools

 Guide to Determining Risk of Complications
Complexity of Medical Decision Making
Risk Presenting Problem Dx Procedure Ordered Management Options Selected
Minimal -1 self-limited or minor problem -Venipuncture -Rest
-X-rays -Gargles
-EKG -Elastic bandages
-EEG
-Urinalysis
-ECHO

Low -2 or more self-limited or minor problems
-1 stable, well- controlled chronic illness
-Acute uncomplicated illness or injury
-Physiologic tests NOT under stress i.e., PFTs -OTC drugs
-Noncardiovascular imaging studies + contrast -Minor surgery without identified risk factors
Barium enema -Physical therapy
-Superficial needle biopsies -Occupational therapy
-Clinical lab tests requiring arterial puncture -IV fluids without additives
-Skin biopsies

Moderate -Mild exacerbation of 1 or more chronic
illnesses
-2 or more stable, chronic illnesses
-Previously undiagnosed NEW problem with
uncertain prognosis (i.e., breast lump)
-Acute illness with systemic symptoms
-Acute complicated injury
-Physiologic tests under stress
Cardiac stress test
Cardiopulmonary exercise test
-Diagnostic endoscopies with NO risk factors
-Deep needle or incisional biopsy
-Cardiovascular imaging studies with contrast
NO identifiable risk factors
Cardiac catheterization
-Obtaining body cavity fluid
Thoracentesis
-Minor surgery WITH identified risk factors
-Elective major surgery with NO identified risk factors
-Prescription drug management
-Therapeutic nuclear medicine
-IV fluids with additives
-Closed treatment of fracture

High -Severe exacerbation or progression of
1 or more chronic illnesses
-Acute or chronic illness or injury that
threatens life or limb
-Abrupt change in neurologic status
-Cardiovascular imaging studies + Risk factors
-Cardiac electro-physiologic tests
-Diagnostic endoscopies + Risk factors
-Discography
-Elective surgery + Risk factors
-Emergency Major surgery
-Parenteral controlled substances
-Drug therapy requiring intensive monitoring
-Decision to not resuscitate or to de-escalate care
due to poor prognosis

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Created by The Lung Doctor for e-Medtools

 Final Determination
Complexity of Medical Decision Making
Number of ≤1 2 3 ≥4
A diagnoses or Minimal Limited Multiple Extensive
treatment options
Highest risk Minimal Low Moderate High
B

Amount and ≤1 2 3 ≥4
C complexity of Minimal or Low Limited Multiple Extensive
data reviewed

Type of decision making Straightforward Low Moderate High

Complexity Complexity Complexity

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Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted

Created by The Lung Doctor for e-Medtools