Straightforward Medical
Decision-Making is the lowest level of Medical
Decision-Making. It is impossible not to qualify for
it. This level complexity is required for very, very
routine encounters such as a level 2 office follow-up (99212) or
a level 1 new office patient (99201). This
level of care is so feeble, you have to wonder why the patient came
to the doctor in the first place. The degree of risk
corresponds to a patient with an insect bite.
Straightforward Medical Decision-Making
(Only two out of three elements are required) |
|
Requires two out of three of the following :
Clinical Example
A 41 year old female referred from an urgent care clinic for left arm pain. She was playing tennis yesterday when she accidentally hit her left forearm with her own racquet. You examine her arm and diagnose a simple contusion for which no further treatment is needed.
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 = 1
In the example, the presence of one “self-limited or minor problem” of a simple arm
contusion adds up to one problem point. 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 points were garnered for review of data.
Risk
Review of the table of risk shows that this encounter qualifies as Minimal Risk due to the presenting problem of “one self-limited or minor problem.” |
| Risk
Level |
Presenting
Problems |
Diagnostic
Procedures |
Management Options
Selected |
Minimal Risk
Requires
ONE of these elements in ANY of the three
categories listed |
One self-limited or minor problem, e.g.,
cold, insect bite, tinea corporis |
Laboratory
tests
Chest
X-rays
EKG/EEG
Urinalysis
Ultrasound/Echocardiogram
KOH
prep
|
- Rest
- Gargles
- Elastic
bandages
- Superficial
dressings
|
|
| Given the above information, the MDM Points table would look like
this: |
|
In this case, all three
components of MDM point toward Straightforward Complexity. This is the lowest possible
level of Medical Decision-Making so it is impossible NOT to qualify
for it.
|
