Medical decision making simplified in guidelines
The draft 2000 Evaluation and Management (E/M) Documentation Guidelines have simplified medical decision making to three levels, with clear requirements that can be cross-referenced to clinical vignettes (currently under development), explains Michelle Green, MPS, RHIA, CMA, CTR, professor in the department of physical & life sciences at Alfred (NY) State College. (For more explanation about the draft 2000 E/M Documentation Guidelines, see p. 155.)
To determine the level of decision making for an encounter, the medical record should include documentation of an assessment and plan for each problem evaluated during the encounter, the draft documentation guidelines say. "The assessment and plan for each problem should include documentation of 1) the status/severity/urgency of the problem(s) and the risk of complications and deterioration; 2) the amount and complexity of data reviewed and differential diagnosis(es); and 3) the diagnostic and therapeutic tests, procedures, and interventions ordered and the treatment plan." Here are the three levels, as explained in the draft documentation guidelines:
A. Low Complexity Medical Decision Making
Typically, the problem(s) addressed will 1) be of low severity, low urgency, and low risk of clinical deterioration and complications; 2) have a limited differential diagnosis and limited review of additional data; and 3) have straightforward diagnostic and/or therapeutic interventions and a straightforward treatment plan. For the purpose of documentation, two of those three elements must either meet or exceed the requirement for low complexity.
B. Moderate Complexity Medical Decision Making
Typically, the problem(s) addressed will 1) be of moderate severity with a low to moderate risk of clinical deterioration; 2) require review of a detailed amount of additional information with an extended differential diagnosis; and 3) require complicated diagnostic and/or therapeutic intervention, with a complicated treatment plan. For the purpose of documentation, two of those three elements must either meet or exceed the requirement for moderate complexity.
C. Highly Complex Medical Decision Making
Typically, the problem(s) addressed will 1) be of high severity with a high risk of complications and clinical deterioration; 2) require review of an extensive amount of additional information with an extensive differential diagnosis; and 3) require highly complex multiple diagnostic and/or therapeutic interventions, with a highly complex treatment plan. For the purpose of documentation, two of those three elements must either meet or exceed the requirement for highly complex medical decision making.
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