Moderate complexity MDM is the second highest level of MDM.  To qualify for moderate complexity MDM, the requirements for two out of the three dimensions of MDM listed below must be satisfied.

• Problems addressed (any of the following)
  • 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
• Data reviewed (must meet the requirements for 1 of 3 of the categories below)
  • Category 1: Tests and documents
    (Requires any combination of 3 of the following)
    • Review of prior external notes
    • Review of results or each unique test
    • Ordering of each unique test
    • Assessment requiring an independent historian
  • Category 2: Interpretation of tests
    • Independent interpretation of a test performed by another physician/NPP
  • Category 3: Discuss management/tests
    • Discussion of management or tests with an external physician/NPP
• Risk: moderate risk
  • Prescription drug management
  • Decision regarding minor surgery with identified 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

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

• level 4 established office visits (99214)
• level 4 new office visits (99204)
• level 2 admission H&Ps (99222)
• level 2 hospital progress notes (99232)
• level 4 outpatient or inpatient consults (99244, 99254)
• level 4 ER visits (99284)
• The second highest level of care for initial nursing facility care visits (99206)
• The second highest level of care for subsequent nursing facility care visits (99309)

For detailed explanations and examples consider enrolling in our courses. It’s not as complicated as it seems.