Medical decision-making (MDM) is based on the complexity of establishing a diagnosis or selecting the management or treatment plan. When reporting an E/M service using the current coding guidelines as published by Current Procedural Terminology (CPT®) and the Centers for Medicare & Medicaid Services (CMS), it is the one key element that seems to be the most difficult to understand, quantify, and document. The descriptors for the level of MDM (ie, straightforward, low, moderate, and high complexity) are vague, making selection of the MDM level confusing.
Although the elements used to measure the MDM level are the same in the CPT and CMS guidelines, the CMS expanded the requirements for documentation and designed a risk table with clinical examples used only to help represent differing levels of complexity. Remember that most payers follow the requirements outlined in the CMS 1995 or 1997 Documentation Guidelines for E/M Services.
The elements of MDM are listed in tables 1, 2, and 3.
Determining the Levels of Medical Decision-Making
To meet the level of complexity, 2 of the 3 elements described must be met. The number of diagnoses or associated risk alone does not determine the MDM level. For example, the patient with repeated occurrences of otitis media may require an increased complexity of decision-making to try to establish a differential diagnosis (eg, allergy) or manage the condition (eg, combination of tests or diagnostic procedures, discussion with another physician, need for tympanostomy).
The 2 elements that are most commonly used as the basis for MDM level selection are the number of diagnoses or management options, and the risk of complication or morbidity and mortality.
The descriptors (minimal, limited, multiple, extensive) under the number of diagnoses or management options in Table 4 are vague and difficult to quantify. Neither CPT nor the CMS has defined the precise number of diagnoses or management options that are necessary to satisfy the requirement for each level of MDM. However, most coders and physicians use the nature of the presenting problem in association with the examples listed under Presenting Problem(s) in Table 5 as a guide, and support with medical record documentation. For example,
Straightforward
One self-limited or minor problem
Example diagnoses
– Uninfected bug bite
– Wart
– Resolved upper respiratory infection (URI)
Documented management options: no treatment necessary versus treatment
Nature of the presenting problem or risk: minimal or self-limited
Low
Two or more self-limited or minor problems
– One stable chronic illness
– Acute uncomplicated illness or injury
Example diagnoses
– Minor feeding problem
– Umbilical drainage
– Stable attention-deficit/hyperactivity disorder (ADHD)
– Asthma
– URI
– Otitis media or acute gastroenteritis without systemic symptoms
Documented management options: prescription drug management versus over-the-counter drugs; rule out allergy, rhinitis versus URI
Nature of the presenting problem or risk: low
Moderate
One or more chronic illnesses with mild exacerbation progression or side effects of treatment
– Two or more stable chronic illnesses
– Undiagnosed new problem with uncertain prognosis
– Acute illness with systemic symptoms
– Three or more self-limited problems (Although not specified in Table 5, by virtue of the number of diagnoses and associated management options, this would be appropriate.)
Examples diagnoses
– Exacerbation of asthma
– Increased behavioral issues associated with ADHD
– Chronic eczema, asthma, cystic fibrosis, or diabetes
– Acute gastroesophageal problems with mild to moderate dehydration, bronchiolitis, or abdominal pain
– Pneumonia
– Chronic otitis media with fever
Documented management options: prescription drug management versus over-the-counter therapy; diagnostic testing; referrals; discussion with other physicians; observation or inpatient hospital admission; rule out respiratory syncytial virus (RSV) versus bronchiolitis; appendicitis versus pelvic inflammatory disease
Nature of the presenting problem or risk: moderate
High
One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
– Acute or chronic illnesses or injuries that pose a threat to life or bodily function; abrupt change in neurologic status
– Four or more stable or chronic illnesses (Although not specified in Table 5, by virtue of the number of diagnoses and associated management options, this would be appropriate.)
Example diagnoses
– Seizure
– Exacerbation of asthma with respiratory distress
– Cyanotic heart disease
– RSV
– Child abuse
– Meningitis
– Sickle cell crisis
Documented management options: admission to inpatient hospital; number and type of treatment administered; diagnostic tests ordered or reviewed
Nature of the presenting problem or risk: high
The level of risk can be established by selecting the highest level of risk from any one of the 3 categories in Table 5. For example, the risk associated with a patient who is managed with over-the-counter medication but has 2 or more stable problems is considered to be of a moderate level (ie, the highest level of risk is under the presenting problem).
A patient who is prescribed over-the-counter medications and has one self-limited problem is considered a low-level risk (ie, the highest level of risk is under the management options). Remember that the level of risk is only one of the elements of the MDM component.
Supporting Medical Record Documentation
Medical record documentation of the elements of MDM is crucial to support the level of MDM and in turn the level of history and physical examination medically necessary to determine the diagnosis(es) and treatment. Keep in mind that documentation to support MDM may be found throughout a progress note—in the history and physical examination portion of the encounter as well as in the assessment and plan. Documentation should include
A list of the problems or diagnoses that are addressed (eg, acute otitis media, impacted cerumen, cough)
Impression; differential diagnoses (eg, asthma vs allergy, rule out reflux)
The level of uncertainty and patient risk (eg, abdominal pain of unclear etiology, fever with neutropenia)
Whether the problem(s) is stable, resolving, worsening, or well-controlled (eg, asthma stable)
Response to treatment (eg, resolved after antibiotics)
Patient compliance with the treatment plan (eg, has discontinued exercise plan)
Support for ordering tests and procedures (eg, exposure to maternal hepatitis B disease, hydronephrosis on prenatal ultrasound)
Review of test results (eg, strep test negative, audiogram normal)
Initiation or revision of treatment plans (eg, increase strength of stimulant medication)
Instructions for prescription management, home care, and follow-up care (eg, return for follow-up in 1 week)
Need for consultations (eg, probable allergy—will consult allergist)
Tip:Physicians are frequently reluctant to list in their medical record the differential diagnoses or conditions that are being ruled out because they are not used to report the diagnosis or reason for the service. However, documenting the additional conditions that were included in the differential diagnosis supports the complexity of the MDM process. For example, if a 3-year-old presents with fever and ear pain and the physician documents that a cough is present and examines the chest, the documentation that pneumonia was ruled out supports the need for the chest examination and increases the number of possible diagnoses considered.
