MDM - E/M University

Understanding your Medical Decision-Making

For E/M services, the level of care selected for any given encounter may be based on the time spent OR on the MDM required for the visit. It is up to the physician to choose to code based on time or based on the MDM. If you are coding based on time, you do NOT need also to satisfy the MDM requirements for any given level of care because the level of care will be driven by time spent.

On the other hand, most physicians find it more efficient to select the level of care based on the MDM required for the visit, instead of based on time. If you do code based on the MDM, then you do NOT need to worry about how much time you spent because the level of care will be driven solely by the MDM required for the encounter. For this reason, it is important to understand the rules for calculating your MDM

The level of MDM is determined based on the problems being addressed, the data reviewed and the risk to the patient.

It is important to understand that only two out of three dimensions of MDM are needed to qualify for any given level of complexity, that is you don’t need the problems, the data and the risk—you only need two out of three.

There are four levels of MDM ranging from straightforward to high complexity based on table below.

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 One stable acute illness Acute uncomplicated illness or injury One acute uncomplicated illness or injury requiring hospital inpatient or observation level care	(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 performed by another physician/NPP Category 3: Discuss management/tests Discussion of management 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 patient procedure risk factors Decision regarding hospitalization or escalation of level of care Decision for DNR or to de-escalate care Parenteral controlled substances
Requires 2 out of 3 to qualify for any given level of MDM

For example, if you are addressing two stable chronic illnesses and you also engage in prescription drug management, you would qualify for moderate complexity MDM based on the problems being addressed and moderate risk, independent of the amount and complexity of the data reviewed.

In our courses, we use clinical examples to illustrate how to interpret the MDM table in daily practice to ensure that the level of care selected for any encounter will be congruent with the intensity of the cognitive labor provided by the physician.