What is High Complexity Medical Decision Making?

What elements of medical decision making qualify as "high complexity?" (For more information, see "Tips for medical documentation and coding.")

Two out of three are required (a large number of diagnoses, complex data to be reviewed, and/or high level of risk):

1. A large number of diagnoses or management options, either:
   • A new problem with additional workup
   • Two established problems that are worse or uncontrolled
   • One established problem that is worse or uncontrolled and two stable problems
   • Four stable problems
   
   
2. A large amount and/or high complexity of data to be reviewed, including five of the following:
   • Review of labs
   • Review of the reports of radiology studies
   • Planning to order new tests
   • Directly visualizing and interpreting a test (an ECG, for example)
   • Deciding to obtain old records or additional history from other sources
   • Summarizing the relevant findings from other sources
   • Discussing test results with the performing/interpreting physician
   
   
3. A high risk of complications, morbidity, or mortality related to either:
   • The problem
     • Chronic with severe exacerbation
     • Acute or chronic which threatens life or limb (severe kidney disease, for example)
     • Abrupt change in neurologic status
   • The diagnostic procedure
     • Cardiovascular imaging with contrast and risk factors
     • Diagnostic endoscopy with risk factors
   • The management
     • IV narcotics
     • Drug therapy requiring monitoring for toxicity
     • The decision to make a patient DNR or withdraw care because of poor prognosis
     • Elective major surgery with risk factors
     • Emergency major surgery

Examples of High Complexity Medical Decision Making:

• Any new problem with additional workup requiring review of labs and radiology reports, ordering of new tests, ECG interpretation, and the decision to obtain information from other sources (for example, a patient's family or old records)
• A COPD exacerbation and uncontrolled hypertension
• A severe pneumonia with workup
• Acute renal failure with workup
• Worsening severe chronic kidney disease and uncontrolled hypertension
• Stable severe chronic kidney disease, stable diabetes, but uncontrolled proteinuria
• Stable severe chronic kidney disease, controlled hypertension, controlled diabetes, controlled proteinuria
• Mental status changes with workup
• Cardiac catheterization with "risk factors" for chest pain
• Endoscopy for GI bleeding
• Pain with workup requiring IV narcotics
• Therapy with heparin, warfarin, gentamicin, or other medications requiring monitoring for toxicity and any new problem with workup
• Withdrawing care or signing a DNR because of poor prognosis
• Any "major surgery" with "risk factors"
• Any emergency "major surgery"

Updated: 10/10/5

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