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

The AMA Levels of Medical Decision Making table indicates: Each unique test, order, or document contributes to the combination of two or combination of three in Category 1”, with levels and guidelines for Category 1 as follows:

Limited

(Must meet the requirements of at least 1 out of 2 categories)

Category 1: Tests and documents

• Any combination of 2 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*

Moderate

(Must meet the requirements of at least 1 out of 3 categories)

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

• Any combination of 3 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)

Extensive

(Must meet the requirements of at least 2 out of 3 categories)

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

• Any combination of 3 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)