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E/M Calculator 2021

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Medical Decision Making 

Number and Complexity of Problems Addressed

Identify each problem, number and complexity of problems addressed and select from the options.

Problem(s)
Self-limited or minor problem
Self-limited or minor problems (2 or more)
Stable chronic illness
Acute, uncomplicated illness or injury
Stable chronic illnesses (2 or more)
Acute complicated injury
Chronic illnesses with exacerbation, progression, or side effects of treatment (1 or more)
Undiagnosed new problem with uncertain prognosis
Acute illness with systemic symptoms
Chronic illnesses with severe exacerbation, progression, or side effects of treatment (1 or more)
Acute or chronic illness or injury that poses a threat to life or bodily function

Amount and/or Complexity of Data to be Reviewed and Analyzed

Reviewed and Analyzed Data
Enter the count of unique test, order, or document in the respective boxes.
Review of prior external note(s) from each unique source
Review of the result(s) of each unique test
Ordering of each unique test
For each category of reviewed and analyzed data identified, select the check box.
Minimal or None
Assessment requiring an independent historian(s)
Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)
Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)
Total:

Risk of Complications and/or Morbidity or Mortality of Patient Management

Use the risk table below as a guide to assign risk factors. It is understood that the table below does not contain all specific instances of medical care; the table is intended to be used as a guide. Select the most appropriate factor(s) in each category. The overall measure of risk is the highest level selected.

Diagnostic Procedure(s) and Management Examples Risk Level
Rest Minimal
Gargles
Elastic bandages
Superficial dressings
Other minimal risk testing or treatment
Minor surgery with no identified risk factors Low
Physical therapy
Occupational therapy
IV fluids without additives
Other low risk testing or treatment
Prescription drug management Moderate
Decision regarding minor surgery with identified patient or procedure risk factors
Decision regarding elective major surgery without identified patient or procedure risk factors
Diagnosis or treatment significantly limited by social determinants of health
Other moderate risk testing or treatment
Drug therapy requiring intensive monitoring for toxicity High
Decision regarding elective major surgery with identified patient or procedure risk factors
Decision regarding emergency major surgery
Decision regarding hospitalization
Decision not to resuscitate or to deescalate care because of poor prognosis
Parenteral controlled substances
Other high-risk testing or treatment
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NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS

The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.

Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems.

  • DG: For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.

• For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled,
  resolving or resolved; or, b) 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" (R/O) diagnosis.

  • DG: The initiation of, or changes in, treatment should be documented Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.
  • DG: If referrals are made, consultations requested or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom the advice is requested.
AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED

The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. 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 is an indication of the complexity of data being reviewed. On
occasion the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or
interpretation; this is another indication of the complexity of data being reviewed.
  • DG: If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service, eg, lab or x-ray, should be documented.
  • DG: The review of lab, radiology and/or other diagnostic tests should be documented. A simple notation such as "WBC elevated" or "chest x-rayunremarkable" is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results.
  • DG: A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented.
  • DG: Relevant findings from the review of old records, and/or the receipt of additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of “Old records reviewed” or “additional history obtained from family” without elaboration is insufficient.
  •  DG: The results of discussion of laboratory, radiology or other diagnostic tests with the physician who performed or interpreted the study should be documented.
  • DG: The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented.
RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY

The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.
  • DG: Comorbidities/underlying diseases or other factors that increase the  complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.
  • DG: If a surgical or invasive diagnostic procedure is ordered, planned or scheduled at the time of the E/M encounter, the type of procedure, eg, laparoscopy, should be documented.
  • DG: If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented.
  • DG: The referral for or decision to perform a surgical or invasive diagnosticprocedure on an urgent basis should be documented or implied.
The following table may be used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because
the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.
Medical decision making consist of establishing the patient's diagnosis, assessing the status of the patient’s condition, and selecting a management option if necessary. The following three components make up medical decision making for office and other outpatient services:
  1. Number and complexity of the problem(s) addressed during the patient encounter.
  2. Amount and/or complexity of data reviewed and analyzed, which includes
    • Medical records
    • Tests (i.e. ordering and review during the same encounter)
    • Other information obtained, ordered, reviewed, and analyzed for the patient encounter.
    • Information obtained from multiple sources
    • Interprofessional communications (not separately reported)
    • Data is further divided into three categories:
      • Tests, documents, orders, or independent historian(s). To meet a threshold, each unique test, order, or document is counted.
      • Independent interpretation of tests.
      • Discussion of management or test interpretation with another physician, qualified healthcare professional, or other appropriate source.
  3. Risk of complications, morbidity, and/or mortality of patient management decisions made during the encounter that is associated with the patient's problem(s), diagnostic procedure(s), and/or treatment(s). This includes the management options selected and options considered, but not selected after those options have been shared with the patient and or family.

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