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Low Complexity mdm
 

 

 

Low 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
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 requring 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
Must meed the requirements for 2 out of 3 dimensions to qualify.

 

 

 

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