| MDM |
Number and complexity of problems addressed |
Amount and/or complexity of data reviewed |
Risk of complications and/or morbidity |
| SF |
- One self-limited or minor problem
|
|
- Minimal risk or morbidity from additional diagnostic testing or treatment
|
| Low |
- Two or more self-limited or minor problems
- One stable chronic illness
- Acute uncomplicated illness or injury
|
(Must meet the requirements for 1 of 2 of the categories)
Category 1: Tests and documents
(Requires any combination of 2 from the following)
-
Review of prior external notes
-
Review of results or each unique test
-
Ordering of each unique test
Category 2: Assessment requiring an independent historian |
- Low risk of morbidity from additional diagnostic testing or treatment
|
| Mod |
- One or more chronic illness with mild exacerbation, progression, or side effects of treatment
- Two or more stable chronic illnesses
- One undiagnosed new problem with uncertain prognosis
- One acute illness with systemic symptoms
- Acute complicated injury
|
(Must meet the requirements for 1 of 3 of the categories)
Category 1: Tests and documents, historian
Any combination of 3 of the following:
- Review of prior external records
- Review of results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Interpretation of tests
- Independent interpretation of a test perfromed by another physician/NPP
Category 3: Discuss management/tests
- Discussion of magagement or tests with an external physician/NPP
|
- Prescription drug management
- Decision regarding minor surgery with identfied patient or procedure risk factors
- Decision regarding elective major surgery without identified patient or procedure risk factors
- Diagnosis or treatment significantly limited by social determinants of health
|
| High |
- Severe exacerbation of chronic illness
- Acute or chronic illnesses that may pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, abrupt change in neurological status
|
Same as moderate, but requirements for 2 out of the 3 categories must be met
|
- Drug therapy requiring intensive monitoring for toxicity
- Decision for elective major surgery with identified pateint or procedure risk factors
- Decision regarding hospitalization
- Decision for DNR or to de-escalate care
|
| Requires 2 out of 3 to qualify for any given level of MDM |
