Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)Ĭategory 3: Discussion of management or test interpretationĭiscussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported) (Must meet the requirements of at least 1 out of 3 categories)Ĭategory 1: Tests, documents, or independent historian(s)Īssessment requiring independent historian(s)Ĭategory 2: Independent interpretation of tests Low risk of morbidity from additional diagnostic testing or treatmentġ or more chronic illnesses with exacerbation, progression, or side effects of treatmentġ undiagnosed new problem with uncertain prognosis (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) Review of the result(s) of each unique test *Ĭategory 2: Assessment requiring independent historian(s) Review of prior external note(s) from each unique source * (Must meet the requirements of at least 1 of the 2 categories) Minimal risk of morbidity from additional diagnostic testing or treatment Risk of Complications and/or Morbidity or Mortality of Patient Management
*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below. Number and Complexity of Problems AddressedĪmount and/or Complexity of Data to be Reviewed and Analyzed
Level of MDM (Based on 2 out of 3 Elements of MDM)