Low Complexity MDM

Low complexity MDM is the second lowest level of MDM.  To qualify for low complexity MDM the requirements for two out of the three dimensions of MDM listed below must be satisfied.

• Problems addressed (any of the following)
  • 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 requiring hospital inpatient or observation level care
• Data reviewed (must meet the requirements for 1 of 2 of the categories below)
  • Category 1: Tests and documents
    (Requires any combination of 2 of 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
• Risk: low risk or morbidity from additional diagnostic testing or treatment

When coding based on the MDM, low complexity MDM is required for:

• level 3 established office visits (99213)
• level 3 new office visits (99203)
• level 1 admission H&Ps (99221)
• level 1 hospital progress notes (99231)
• level 3 outpatient or inpatient consults (99243, 99253)
• level 3 ER visits (99283)
• The second lowest level of care for initial nursing facility care visits (99205)
• The second lowest level of care for subsequent nursing facility care visits (99308)