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
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
- 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
, or high
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.