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high complexity mdm



High Complexity MDM

The table below is from the 2021 E/M guidelines, first released in 2021, with minor revisions added in 2023.

MDM Number and complexity of problems addressed Amount and/or complexity of data reviewed Risk of complications and/or morbidity
  • 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

(Must meet the requirements for 2 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
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision for elective major surgery with identified pateint or procedure risk factors
  • Decision regarding hospitalization or escalation of level of care
  • Decision for DNR or to de-escalate care
  • Parenteral controlled substances
Must meet the requirements for 2 out of 3 dimensions to qualify.




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