Answer to Question 1
Answers should include the following:
The first element of medical decision making, number of diagnoses and management options, addresses the physician's familiarity with the presenting problem and any need for diagnostic testing to discern the possible, probable, rule-out, or final diagnosis, or diagnoses.
The second element of medical decision making specifically addresses the amount and/or complexity of data to be reviewed during the collection of any clinical, laboratory, pathology, or radiology results.
Answer to Question 2
Answers should include the following:
The amount of data addresses information could be obtained through ordering diagnostic testing or reviewing the results of diagnostic testing. It could be obtained through acquiring and reviewing the patient's old medical records, which could inform the physician about the nature of the presenting problem. It could also be obtained through collecting additional history from the patient's family or caretaker or from a supplemental source.
Ultimately, the nature of the data to be reviewed could be referred to as any clues identified and used by the performing physician for the discernment of diagnosing the presenting problem. Only the performing physician can ensure the complete documentation of any identified clues, thus underlining the importance of the physician's thorough documentation of the E/M service visit.
The complexity of data addresses the variation of the diagnostic testing and the identified results, as well as how the data informs the process for identifying the diagnosis.
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