Answer: High Complexity
For medical decision making, the number of diagnosis was greater than four points—one established problem, stable, equals one point; one established problem, worsening, equals two points; and one new problem with workup requested equals four points. This adds up to a total of seven points, making this component extensive.
The amount of data reviewed and/or ordered equals two points—one point for the labs and one point for the X-rays. This adds up to two points, making the amount and complexity of data component limited.
Lastly, the level of risk was high because of the drug therapy requiring intensive monitoring for toxicity.
Only two out of the three components are needed for determination of the medical decision-making level. The medical decision making is of high complexity.