E/M: Reviewing amount and/or complexity of data

For the element of medical decision making addressing the amount and/or complexity of data to be reviewed and analyzed, the AMA Levels of Medical Decision Making table indicates: *Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1, with categories, levels and guidelines as follows:

Limited

(Must meet the requirements of at least one out of two categories)

Category 1: Tests and documents

• Any combination of two from the following:
  • Review of prior external note(s) from each unique source*;
  • Review of the result(s) of each unique test*;

  • Ordering of each unique test*

    or

Category 2: Assessment requiring an independent historian(s)

• (For the categories of independent interpretation of tests and discussion of tests and discussion of management or test interpretation, see moderate or high)

Moderate

(Must meet the requirements of at least one out of three categories)

Category 1: Tests, documents, or independent historian(s)

• Any combination of three from the following:
  • Review of prior external note(s) from each unique source*;
  • Review of the result(s) of each unique test*;
  • Ordering of each unique test*;
  • Assessment requiring and independent historian(s)

or

Category 2: Independent interpretation of tests

• Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)

or

Category 3: Discussion of management or test interpretation

• Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)

Extensive

(Must meet the requirements of at least two out of three categories)

Category 1: Tests, documents, or independent historian(s)

• Any combination of three from the following:
  • Review of prior external note(s) from each unique source*;
  • Review of the result(s) of each unique test*;
  • Ordering of each unique test*;
  • Assessment requiring and independent historian(s)

or

Category 2: Independent interpretation of tests

• Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)

or

Category 3: Discussion of management or test interpretation

• Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)