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.
| Considerations . | Circumstances That May Increase Complexity When Determining Treatment Management . |
|---|---|
| • The number and types of problems or conditions that are addressed • The number of management options that are being considered in the treatment of the patient • The complexity involved in establishing the diagnosis and plan (eg, referral, prescriptions, diagnostic tests) • The nature of the presenting problem . | • There is an undiagnosed problem. • A problem or condition is unresponsive to treatment. • A number of problems or conditions are being addressed. • One problem or condition may have several management options. • The risk of morbidity without treatment is moderate or high. . |
| Considerations . | Circumstances That May Increase Complexity When Determining Treatment Management . |
|---|---|
| • The number and types of problems or conditions that are addressed • The number of management options that are being considered in the treatment of the patient • The complexity involved in establishing the diagnosis and plan (eg, referral, prescriptions, diagnostic tests) • The nature of the presenting problem . | • There is an undiagnosed problem. • A problem or condition is unresponsive to treatment. • A number of problems or conditions are being addressed. • One problem or condition may have several management options. • The risk of morbidity without treatment is moderate or high. . |
| Considerations . | Circumstances That May Increase Complexity . |
|---|---|
| • The number of diagnostic tests ordered or reviewed • The complexity of the tests or procedures and their review • Nature of the presenting problem . | • The combination of types of diagnostic tests (eg, pulse oximetry, chest radiograph, pulmonary function test) that are required (usually constitutes a higher level of complexity in this category, while performing 1 or 2 tests within a category of service [eg, hematocrit and urinalysis] usually constitutes a minimal level). • Need to review and summarize old medical records. • Need to discuss results with another physician. • Need to order or review invasive or complex diagnostic tests (eg, lumbar puncture, magnetic resonance imaging, computed tomography, imaging studies). • Need to obtain additional history and summarization in the medical record. • Poor historian or no history. • Problems or complaints are vague. • Need for advice from others. . |
| Considerations . | Circumstances That May Increase Complexity . |
|---|---|
| • The number of diagnostic tests ordered or reviewed • The complexity of the tests or procedures and their review • Nature of the presenting problem . | • The combination of types of diagnostic tests (eg, pulse oximetry, chest radiograph, pulmonary function test) that are required (usually constitutes a higher level of complexity in this category, while performing 1 or 2 tests within a category of service [eg, hematocrit and urinalysis] usually constitutes a minimal level). • Need to review and summarize old medical records. • Need to discuss results with another physician. • Need to order or review invasive or complex diagnostic tests (eg, lumbar puncture, magnetic resonance imaging, computed tomography, imaging studies). • Need to obtain additional history and summarization in the medical record. • Poor historian or no history. • Problems or complaints are vague. • Need for advice from others. . |
| Considerations . | Circumstances That May Increase Complexity . |
|---|---|
| • The overall risk associated with the patient presenting problem(s) (ie, comorbidities, underlying diseases or factors) • Risk related to the disease process that is expected between the present encounter and the next one • Risk during and immediately following any diagnostic tests or procedures • Risk associated with the treatment or management options • Nature of the presenting problem | • Poor patience compliance • Uncertain prognosis • Increased probability of functional impairment • Need for invasive procedure or surgery • Need for prescription drug management • Need for intravenous therapy • Need for intensive or critical care |
| Considerations . | Circumstances That May Increase Complexity . |
|---|---|
| • The overall risk associated with the patient presenting problem(s) (ie, comorbidities, underlying diseases or factors) • Risk related to the disease process that is expected between the present encounter and the next one • Risk during and immediately following any diagnostic tests or procedures • Risk associated with the treatment or management options • Nature of the presenting problem | • Poor patience compliance • Uncertain prognosis • Increased probability of functional impairment • Need for invasive procedure or surgery • Need for prescription drug management • Need for intravenous therapy • Need for intensive or critical care |
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
| Level of Medical Decision-Making | Number of Diagnoses or Management Options | Amount or Complexity of Data | Risk of Complications or Morbidity and Mortality |
| Straightforward | Minimal | Minimal or none | Minimal |
| Low complexity | Limited | Limited | Low |
| Moderate complexity | Multiple | Moderate | Moderate |
| High complexity | Extensive | Extensive | High |
| Level of Medical Decision-Making | Number of Diagnoses or Management Options | Amount or Complexity of Data | Risk of Complications or Morbidity and Mortality |
| Straightforward | Minimal | Minimal or none | Minimal |
| Low complexity | Limited | Limited | Low |
| Moderate complexity | Multiple | Moderate | Moderate |
| High complexity | Extensive | Extensive | 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).
| Level of Risk | Presenting Problem(s) | Diagnostic Procedure(s) Ordered | Management Options Selected |
| Minimal | • One self-limited or minor problem, eg, cold, insect bite, tinea corporis | • Laboratory tests requiring venipuncture • Chest radiographs • Electrocardiogram/electroencephalogram • Urinalysis • Ultrasound, eg, echocardiography | • Rest • Gargles • Elastic bandages • Superficial dressings |
| Low | • Two or more self-limited or minor problems • One stable chronic illness, eg, well-controlled hypertension, non–insulin-dependent diabetes, cataract, benign prostatic hyperplasia • Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain | • Potassium hydroxide preparation • Physiologic tests not under stress, eg, pulmonary function tests • Non-cardiovascular imaging studies with contrast, eg, barium enema • Superficial needle biopsies • Clinical laboratory tests requiring arterial puncture • Skin biopsies | • Over-the-counter drugs • Minor surgery with no identified risk factors • Physical therapy • Occupational therapy • Intravenous fluids without additives |
| 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, eg, lump in breast • Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis • Acute complicated injury, eg, head injury with brief loss of consciousness | • Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test • Diagnostic endoscopies with no identified risk factors • Deep needle or incisional biopsy • Cardiovascular imaging studies with contrast and no identified risk factors, eg, arteriogram, cardiac catheterization • Obtain fluid from body cavity, eg, lumbar puncture, thoracentesis, culdocentesis | • Minor surgery with identified risk factors • Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors • Prescription drug management • Therapeutic nuclear medicine • Intravenous fluids with additives • Closed treatment of fracture or dislocation without manipulation |
| 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, eg, multiple trauma, acute myocardial infarction, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure • An abrupt change in neurologic status, eg, seizure, transient ischemic attack, weakness, sensory loss | • Cardiovascular imaging studies with contrast with identified risk factor • Cardiac electrophysiologic tests • Diagnostic endoscopies with identified risk factors • Discography | • Elective major surgery (open, percutaneous, or endoscopic) with identified risk factors • Emergency major surgery (open, percutaneous, or endoscopic) • Parenteral controlled substances • Drug therapy requiring intensive monitoring for toxicity • Decision not to resuscitate or to de-escalate because of poor prognosis |
| Level of Risk | Presenting Problem(s) | Diagnostic Procedure(s) Ordered | Management Options Selected |
| Minimal | • One self-limited or minor problem, eg, cold, insect bite, tinea corporis | • Laboratory tests requiring venipuncture • Chest radiographs • Electrocardiogram/electroencephalogram • Urinalysis • Ultrasound, eg, echocardiography | • Rest • Gargles • Elastic bandages • Superficial dressings |
| Low | • Two or more self-limited or minor problems • One stable chronic illness, eg, well-controlled hypertension, non–insulin-dependent diabetes, cataract, benign prostatic hyperplasia • Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain | • Potassium hydroxide preparation • Physiologic tests not under stress, eg, pulmonary function tests • Non-cardiovascular imaging studies with contrast, eg, barium enema • Superficial needle biopsies • Clinical laboratory tests requiring arterial puncture • Skin biopsies | • Over-the-counter drugs • Minor surgery with no identified risk factors • Physical therapy • Occupational therapy • Intravenous fluids without additives |
| 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, eg, lump in breast • Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis • Acute complicated injury, eg, head injury with brief loss of consciousness | • Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test • Diagnostic endoscopies with no identified risk factors • Deep needle or incisional biopsy • Cardiovascular imaging studies with contrast and no identified risk factors, eg, arteriogram, cardiac catheterization • Obtain fluid from body cavity, eg, lumbar puncture, thoracentesis, culdocentesis | • Minor surgery with identified risk factors • Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors • Prescription drug management • Therapeutic nuclear medicine • Intravenous fluids with additives • Closed treatment of fracture or dislocation without manipulation |
| 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, eg, multiple trauma, acute myocardial infarction, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure • An abrupt change in neurologic status, eg, seizure, transient ischemic attack, weakness, sensory loss | • Cardiovascular imaging studies with contrast with identified risk factor • Cardiac electrophysiologic tests • Diagnostic endoscopies with identified risk factors • Discography | • Elective major surgery (open, percutaneous, or endoscopic) with identified risk factors • Emergency major surgery (open, percutaneous, or endoscopic) • Parenteral controlled substances • Drug therapy requiring intensive monitoring for toxicity • Decision not to resuscitate or to de-escalate because of poor prognosis |
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.
