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2021 MDM Table
 

 

 

The 2021 Medical Decision-Making Table

Effective January 1, 2021

The table below is part of the 2021 E/M guidelines for new and established office patients. All other encounters (for example, hospital visits, nursing home visits, ER visits, etc.) will continue to utilize the 1995 or 1997 MDM rules. The table below appplies only to new and established office visits.

For a detailed exploration of the 2021 guidelines including clinical examples of each level of care and a deep dive into the new table of medical decision-making, consider signing up for one of our 2021 update courses here.

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 or none
  • 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

 

 

 

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