Amount and/or Complexity of Data to be Reviewed and Analyzed
•The amount and/or complexity of data to be reviewed and analyzed. This data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter.
oData is divided into three categories
▪Tests, documents, orders, or independent historian(s).
▪Independent interpretation of tests
▪Discussion of management or test interpretation with an external physician or other qualified healthcare professional or appropriate source.
oThe level for the Amount and/or Complexity of Data to be Reviewed and Analyzed is displayed in the upper right corner of the screen. The lowest level, Minimal or None, does not require any data and may be used to meet a straightforward level of Medical Decision Making.
oWhen the mouse is positioned over an element, additional information from the documentation guidelines will appear in the light blue help box across the bottom of the page as an additional reference.
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