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The following information pertains only to the 1995 and 1997 E/M guidelines. For information, regarding the 2021 buidelines for new and established office visits, click here.

High Complexity Medical Decision-Making truly is complex.  Either the patient is quite ill or the physician must review a significant amount of primary data.  This level of MDM is required for a level 3 hospital progress note (99233) or a level 5 office visit with an established patient (99215).  The patient would need to have a severe exacerbation of a chronic problem or an acute illness which threatens life or bodily function to qualify for this level of risk.  The data reviewed would have to be quite extensive to reach the threshold for high complexity MDMThis set of circumstances would be unusual for follow-up encounters, but may occur quite often during initial encounters. 

High 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)   Four problem points
2)   Four data points
3)   High risk

Clinical Example

A 68 year old male presents with chest pain with a good story for unstable angina.  The patient has a history of hypertension (which is not well controlled on presentation) as well as stable diabetes.  You personally review the EKG and CXR, order troponins and start the patient on a heparin drip.  You also order an echocardiogram.

Problem Points

For the example , the problem points are 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 = 7

In the example four problem points are garnered for chest pain which will obviously require further work-up.  The patient’s hypertension is not controlled so this counts as two points.  The diabetes is controlled and counts as one point.  Therefore seven total points are scored.  Note that even thought the major problem is chest pain (and concern for acute MI), the diabetes and hypertension should also be counted in the problem points because their presence significantly impacts the treatment and prognosis of the patient’s suspected coronary disease.

Data Points

The data points for the example 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 = 6

Two data points EACH are scored for the physician personally reviewed the chest X-ray and EKG tracing and recorded the findings in the chart.  One data point is scored for ordering an echocardiogram.  One point is scored for reviewing/ordering lab tests. 


A review of the table of risk shows that the clinical example qualifies as being of High Risk due to the presenting problems of an “acute or chronic illness or injury, which poses a threat to life or bodily function.” 
Risk Level Presenting Problems Diagnostic Procedures Management Options Selected
High Risk

Requires any ONE of these elements in ANY of the three categories listed
  • One or more chronic illness, with severe exacerbation or progression
  • Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF
  • An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss
  • Cardiovascular imaging, with contrast, with identified risk factors
  • Cardiac EP studies
  • Diagnostic endoscopies, with identified risk factors
  • Discography
  • Elective major surgery (open, percutaneous, endoscopic), with identified risk factors
  • Emergency major surgery (open, percutaneous, endoscopic)
  • Parenteral controlled substances
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision not to resuscitate, or to de-escalate care because of poor prognosis
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
In this case, all three dimensions of Medical Decision-Making, (seven problem points, five data points and High Risk) add up to High Complexity Medical Decision-Making .

E/M University Coding Tip : Although the risk threshold is quite high for this type of MDM, the physician should remember that only two out of three elements of MDM are required to qualify for any particular level of complexity.  This means that the data reviewed points and problem points can be used to qualify for high complexity MDM, even if the level of risk is only moderate.  This is often the case for initial encounters (such as admission H&Ps, consults and new office patients).  Therefore before ruling out the possibility of qualifying for high complexity MDM based on risk, it is always a good idea to double check the data reviewed points and problem points.

E/M University Coding Tip : Many physicians overlook the fact that the use of parenteral controlled substances or the decision change to DNR status or to de-escalate care due to poor prognosis both qualify for high risk. 

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