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Choosing the right level of complexity in medical decision-making
When deciding which code to use, you need to look beyond patient risk

Keywords: Choosing the right level of complexity in billing for medical decision-making


by Kristy Welker, CPC



When choosing codes that reflect the complexity of their medical decision-making, many physicians think only of patients' "risk," from potential complications that may arise or even the chance that a patient may die.


Stay up-to-date with coding changes: Coding Tips & Strategies for 2014


But focus only on risk, and you may over-code. That's because risk is only one of three components you need to consider when determining the complexity of medical decision- making.

CPT's definition of decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option. The CPT recognizes four complexity levels—straightforward, low, moderate and high—as measured by the following three components:

  • the risk of significant complications, morbidity and/or mortality, as well as co-morbidities, associated with a patient's presenting problem(s), diagnostic procedure(s) and/or possible management options;
  • the number of diagnoses and management options you have to consider; and
  • the amount and/or complexity of medical records, diagnostic tests and/or other information that you need to obtain, review and analyze.


When billing for any level of decision-making, you must meet or exceed the requirements for that particular level in two of the three components. That in itself is a pretty complex calculation!

Here's a look at the three elements to consider when choosing the right level of complexity.

1. Weighing patient risk
When it comes to decision-making complexity for patient risk, choose the highest level of risk you need to take into account for that patient, according to the risk categories as outlined in "How patient risk factors into the complexity of decision-making.

Pick the highest level of risk that you have to consider among three different risk-factor categories: presenting problem, diagnostic procedure(s) ordered and management options selected. If, for instance, you prescribe medications to treat a patient with a chronic stable illness (without exacerbation), the service would qualify for "moderate" complexity. While the "presenting problem" itself is considered low risk, you'd be able to base the complexity on the prescription drug treatment outlined in the "management options" column.

2. Diagnoses, management options
Next, consider the number of diagnoses and management options, which have their own criteria and scoring system:

Diagnosis and management options
  • Self limited/minor (2 maximum): x1 point for each minor problem, up to a maximum total of 2 points
  • Established problem, stable: x1 point for each stable problem
  • Established problem, worsening: x2 points for each worsening problem
  • New problem, no work-up (3 maximum): x3 points for each problem that doesn't require ancillary testing
  • New problem, additional work-up: x4 points for each problem that requires ancillary testing


You receive more points for treating a new problem than for one you previously addressed. You likewise can claim more points for dealing with worsening problems than for those that are stable. (Document these in your history with "patient presents with new onset of" or "patient worse today.") You also receive additional points for any problem that needs additional work-up.

Be sure to count (and document) any underlining conditions that affect your care management. If the patient is hypertensive, for example, and you need to take that into account to treat the presenting problem, list hypertension as a subsequent diagnosis, even if it is well-controlled. Then give yourself an extra point in the "established problem, stable" category and add it to your overall score.

Here's an example: If you had a patient presenting with a new problem that requires no additional work-up, you would score three points. If, however, the patient had another diagnosis that you needed to consider, you would take a total of four points, which qualifies as "high" complexity in the diagnosis and management component.

3. Data amount and complexity
There is one more component to take into account: the amount or complexity of patient data. The following table lists the criteria and scoring system:

Amount and complexity of data
  • Lab tests, ordered and reviewed: 1 point total for all labs
  • X-rays, ordered or reviewed: 1 point total for all X-rays
  • Medical tests, ordered or reviewed: 1 point total for all medical tests
  • Discussing test results with performing physician: 1 point
  • Obtaining old medical record/history from other sources: 1 point
  • Reviewing/summarizing old medical record: 2 points
  • Independent visualization: 2 points

    Total points required
  • Minimum: 0-1
  • Low: 2
  • Moderate: 3
  • high: >3

Note that you receive only one point for all the data you review in any one category. If you ordered or reviewed three different lab tests, for instance, you can claim only one point. But if you ordered or reviewed a lab test, an X-ray and an EKG, you receive a total of three points, which supports a moderate level of complexity for this component.

You also can claim points for discussing test results with the physician who performed the test or for obtaining history from an old medical record or from another source, such as a language interpreter.

And you can add two points for reviewing or summarizing an old medical record and for an independent visualization of an image, tracing or specimen.

Putting it all together
Now that you've gathered all of the elements to decide the complexity of your decision-making, how do you put them together to pick the right code?

You should start by considering patient risk, in part because that's usually the easiest element to determine. Once you choose that level of complexity, you can turn to the other two elements. Be sure, however, that you meet or exceed the point scores for that same complexity level to claim that level of complexity for the entire service.

Here's another example: Say that you choose a moderate level of complexity in the patient risk component. You would need to score at least three points (or more) in either the diagnosis and management options or the amount and complexity level of decision-making for the entire service.

One final point: Always remember to document the thought processes you use to arrive at a diagnosis or management plan. Many physicians fail to note the routine tests they order or the many factors they take into account. That means they're not able to bill for the complexity of the decision-making they actually bring to patient care.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at kristywelker@hotmail.com. We'll try to answer your questions in a future issue of Today's Hospitalist.
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