Number of Diagnoses and/or Management Options
“Here are some important points to keep in mind when documenting the number of diagnoses or management options. You should document:
1) 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:
A) 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
B) 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.
2) The initiation of, or changes in, treatment, which includes a wide range of management options such as patient instructions, nursing instructions, therapies, and medications
3) 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
“Here are some important points to keep in mind when documenting the 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 appropriate. A notation of “Old records reviewed” or “Additional history obtained from family” without elaboration is not sufficient.
• Discussion about the results of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study.
• The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician.”
Risk of Significant Complications, Morbidity, and/or Mortality
“The risk of significant complications, morbidity, and/or mortality is based on the risks associated with these categories: 1. Presenting problem(s); 2. Diagnostic procedure(s); 3. Possible management options
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 encounter.
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 determines the overall risk.
Here are some important points to keep in mind when documenting the level of risk. You should document:
• Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or
mortality.
• The type of procedure, if a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter.
• The specific procedure, if a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter.
• The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis. This point may be implied.”
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