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Moderate Complexity MDM
The table below is from the 2021 E/M guidelines, first released in 2021, with minor revisions added in 2023.
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MDM |
Number and complexity of problems addressed |
Amount and/or complexity of data reviewed |
Risk of complications and/or morbidity |
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
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(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
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- 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
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Must meet the requirements for 2 out of 3 dimensions to qualify. |
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