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MODERATE COMPLEXITY
MEDICAL DECISION MAKING
 

 
Moderate Complexity Medical Decision-Makingrepresents the cognitive labor “sweet spot” for most physicians.  You may not be surprised to learn that Moderate MDM is required for a "routine" encounter like a level 2 hospital progress note (99232), but you may not have realized that it also represents the cognitive labor requried for a level 4 office visit with an established patient (99214).  A patient with one chronic illness with a mild exacerbation or two stable chronic illnesses would satisfy the risk requirement for this level of medical decision-making. 

Moderate Complexity Medical Decision-Making

(Only two out of three elements are required)
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
Requires two out of three of the following:
1)   Three problem points
2)   Three data points
3)   Moderate risk

Clinical Example

An established office patient with diabetes, hypertension and dyslipidemia all of which are optimally controlled.  You check routine labs and schedule return visit in four months.  No changes are made to any medications. 

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 = 3

The three established and stable problems of hypertension, diabetes and dyslipidemia are added up individually for a total of three 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 = 1

This encounter rates only one data point for review of labs.  Notice that you DO NOT get an additional data point for also ordering labs.  No double dipping is allowed!

Risk

A review of the table of risk shows that this encounter qualifies as being of Moderate Risk due to the presenting problems of “two or more stable chronic illnesses.” 
Risk Level Presenting Problems Diagnostic Procedures Management Options Selected
Moderate Risk

Requires any ONE of these elements in ANY of the three categories listed
  • One or more chronic illness, with mild exacerbation, progression, or side effects of treatment
  • Two or more stable chronic illnesses
  • Undiagnosed new problem, with uncertain prognosis, e.g., lump in breast
  • Acute illness, with systemic symptoms
  • Acute complicated injury, e.g., head injury, with brief loss of consciousness
  • Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test
  • Diagnostic endoscopies, with no identified risk factors
  • Deep needle, or incisional biopsies
  • Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization
  • Obtain fluid from body cavity, e.g., LP/thoracentesis
  • Minor surgery, with identified risk factors
  • Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors
  • Prescription drug management
  • Therapeutic nuclear medicine
  • IV fluids, with additives
  • Closed treatment of fracture or dislocation, without manipulation
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

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