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MDM Points
 

 
MDM Points Table
(Two out of three must be present to qualify for a given level of MDM)
Overall MDM Problem Points Data Points Risk
Straightforward Complexity 1 1 Minimal
Low complexity 2 2 Low
Moderate Complexity 3 3 Moderate
High Complexity 4 4 High
Example

 Suppose you see a patient in the office with stable diabetes and sub-optimally controlled hypertension.  After checking routine labs, you decide to increase the patient’s lisinopril from 10 to 20 mg po qd.  If you calculate the individual points and assign a level of risk, the MDM table for this encounter would look like this:
Overall MDM Problem Points Data Points Risk
Straightforward Complexity 1 1 Minimal
Low complexity 2 2 Low
Moderate Complexity 3 3 Moderate
High Complexity 4 4 High
Since it only takes two out of three elements to qualify for any level of MDM, it is clear that this encounter qualifies     for “Moderate Complexity” medical decision-making because of:
    • Three Problem Points  (one point for diabetes-- established problem, two points for hypertension—established problem,  worsening)
    • One  Data Point for reviewing labs
    • Moderate Risk due to the management option selected of “prescription drug management”

    E/M University Coding Tip: The MDM point system provides a repeatable and objective way for the physician to measure the cognitive labor required to address the clinical issues of any encounter.  Many physicians systematically underestimate the value of their medical decision-making.  This occurs because there is a tendency to equate “routine” thought processes with “straightforward” medical decision-making which is simply not true.  Utilizing the objective MDM point system can help you avoid this self-deprecating pattern of behavior. 
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