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Each type is defined by meeting or exceeding the minimum requirements for two of three elements (see Table 1): In this month's column, we'll focus on quantifying the amount and complexity of data, like medical records, diagnostic tests and other information, that must be obtained, reviewed and analyzed.Data review complexity is classified as minimal, limited, moderate or extensive (see Table 1) , but how does one determine which of these applies in any particular case?In general, only the information that you provide, or the choices you make while visiting a web site, can be stored in a cookie.For example, the site cannot determine your email name unless you choose to type it.
Determine the complexity of data review for each encounter using a point score if necessary.
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The December 2010 Documentation Guidelines for Evaluation and Management (E/M) Services from the CMS Medical Learning Network (available online) does not give specific guidance on how much data review is required for each level of complexity, but does discuss at length what to consider and document in the medical record.
In a nutshell, the decision is subjective and based on a clinician's judgment, but steps include: To standardize criteria for the complexity of data review, the Marshfield Clinic in Marshfield, Wis., developed a scoring system in 1995 that has become a generally accepted industry standard.