Low Complexity Medical Decision-Making requires only slightly more intellectual energy than straightforward MDM. The acuity of care remains minimal. For example, this level of MDM is required for a level 3 office visit (99213) or a level 3 office consult (99243). The degree of risk remains quite low and corresponds to a patient with one chronic illness which is completely stable. If there is an acute problem, it should be an uncomplicated clinical issue such as allergic rhinitis, cystitis or a sprained ankle.
Lw Complexity Medical Decision-Making
(Only two out of three elements are required) |
|
| Requires two out of three of the following: |
1) Two problem points
2) Two data points
3) Low risk
Clinical Example
Established office patient with osteoarthritis of the knees, which is no longer controlled with tylenol. You examine the patient and switch to OTC ibuprofen. No labs are reviewed.
Problem Points
In the example above, the clinical problems would be scored as follows: |
| Problems |
Points |
Example |
| Self-limited or minor (maximum of 2) |
1 |
 |
| Established problem, stable or improving |
1 |
|
| Established problem, worsening |
2 |
|
| New problem, with no additional work-up planned (maximum of 1) |
3 |
|
| New problem, with additional work-up planned |
4 |
|
|
Total Problem Points = 2
The presence of the one “established problem, worsening” of osteoarthritis adds up to two problem points.
Data Points
The data points for the above encounter are scored as follows: |
| Data
Reviewed
|
Points |
Example |
| Review or order
clinical lab tests |
1 |
|
| Review or order
radiology test (except heart catheterization or echo) |
1 |
|
| Review or order
medicine test (PFTs, EKG, cardiac echo or cath) |
1 |
|
| Discuss test
with performing physician |
1 |
|
| Independent
review of image, tracing, or specimen |
2 |
|
| Decision to
obtain old records |
1 |
|
| Review and
summation of old records |
2 |
|
|
Total Data Points = 0
No data points are scored for this encounter because no eligible data was reviewed.
Risk
Review of the table of risk shows that this encounter qualifies as Low Risk due to the management option of “over-the-counter drugs.” |
| Risk
Level |
Presenting
Problems |
Diagnostic
Procedures |
Management Options
Selected |
Minimal Risk
Requires ONE of these elements in ANY of the three
categories listed |
- Two or more self-limited or minor problems
- One stable chronic illness, e.g., well controlled HTN, DM2, cataract
- Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain
|
- Physiologic tests not under stress, e.g., PFTs
- Non-cardiovascular imaging studies with contrast, e.g., barium enema
- Superficial needle biopsy
- ABG
- Skin biopsies
|
- Over the counter drugs
- Minor surgery, with no identified risk factors
- Physical therapy
- Occupational therapy
- IV fluids, without additives
|
|
| Given the above information, the MDM Points table would look like this: |
| Overall MDM
|
Problem Points |
Data Reviewed Points |
Risk |
| Straightforward Complexity |
1 |
1 |
Minimal |
| Low complexity |
2 |
2 |
Low |
| Moderate Complexity |
3 |
3 |
Moderate |
| High Complexity |
4 |
4 |
High |
|
Since only two out of three factors must meet or
exceed the requirements for any given level of Medical
Decision-Making, two problem points, no data points and Low Risk add
up to Low
Complexity Medical
Decision-Making
|
