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Department of Neurology
 

NEUROLOGY: CODING AND DOCUMENTATION:

Determination of the Level of Amount / Complexity of Data
The level of medical decision making also depends on tests you review or order; outside records you review; physicians whom you discuss the case with; and directly interpreting imaging studies. The level of Amount and Complexity of Data is calculated by adding up points based on the table below. This is what auditors use to review your notes.
 
Have you reviewed, ordered or called for: NUMBER POINTS SCORE
Clinical laboratory test max = 1 1  
Radiology test max = 1 1  
Medical diagnostic test max = 1 1  
Discussed the test results with referring or interpreting physician any 1  
Directly visualized imaging (CT, MRI), EEG tracing, or EMG data done by another physician (not just the report) any 2  
Decision to obtained old records and/or obtain history from someone other than the patient any 1  
Reviewed and summarized old records or history from sources other than the patient any 2  
    TOTAL:  

Once the total points are summed, the proper level can be determined from the table below:

Level of Amount / Complexity of Data Total Points
Minimal 1 Point
Limited 2 Points
Moderate 3 Points
Extensive ³ 4 Points

Examples
 

• A consult patient is seen. You review the blood work (1 point), report of the Chest X-ray (1 point), personally view the MRI (1) and order an EEG (1 point). The level of amount/complexity of the data is Extensive (4 points).

•  You see a patient in follow-up. You order blood work (1 point), an EMG (1 point) and call the referring physician to discuss the case (1 point). The level of amount/complexity of the data is Moderate (3 points).

•  A patient from a nursing home is seen. You review and summarize the patient's records from the nursing home (2 points), call the patient's nurse to obtain additional history (1 point) and order blood work (1 point). The level of amount/complexity of the data is Extensive (4 points).