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moderate complexity mdm



Moderate 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
  • 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
Must meet the requirements for 2 out of 3 dimensions to qualify.




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