The medical documentation of the E/M service visit supports the following levels of medical decision-making element: Number of diagnoses and/or management options: extensive (new problem with workup) Amount and/or complexity of data reviewed:
minimal (ordered X-ray, reviewed lab tests) Risk of complication, comorbidity and/or mortality: moderate (undiagnosed new problem with uncertain prognosis) Which of the following levels best reflects the overall medical decision-making complexity? a. Straightforward complexity
b. Low complexity
c. Moderate complexity
d. High complexity
Question 2
Identify the overall level of medical decision-making complexity for the following clinical excerpt: An 85- year- old woman presents to orthopedic surgeon due to confirmed fracture of L1 vertebra. Orthopedic surgeon recommends balloon kyphoplasty.
No diagnostic testing required; however, orthopedic surgeon independently reviewed images of positive bone scan. Extensive discussion with patient regarding risks of surgery, potential complications, and postsurgical expectations. Patient agrees to kyphoplasty. Surgery scheduled for next week. a. Straightforward complexity
b. Low complexity
c. Moderate complexity
d. High complexity
Example of variance documentation
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