Assessing Moderate-Level 4 Risk in Medical Decision-Making

Monday, May 29, 2023

In the previous issue of Coffee & Coding, we reviewed Low Level 3 MDM. Now let’s review Moderate Level 4.

Let’s start with the guidelines listed by AMA:


  • 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment;


  • 2 or more stable, chronic illnesses;


  • 1 undiagnosed new problem with uncertain prognosis;


  • 1 acute illness with symptoms;


  • 1 acute, complicated injury
(Must meet the requirements of at least 1 out of 3 categories)

Category 1: Test, documents, or independent historian(s)

  • Any combination of 3 from the following:
    • Review of prior external note(s) from each unique source;
    • Review of the result(s) of each unique test;
    • Ordering of each unique test;
    • Assessment requiring an independent historian(s)

Category 2: Independent interpretation of tests

  • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);

Category 3: Discussion of management or test interpretation

  • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)
Moderate risk of morbidity from additional diagnostic testing or treatment
Examples only:

  • 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

As you may have observed, compared to Low Level 3, there are more combinations that would result in a Moderate Level 4 MDM, making this level more complicated and less black-and-white.

From what our physicians tell us, the area that presents the most challenges is “Data” (column 2). Let’s explore why.

First, the guidelines state the data must meet 1 of the 3 categories. For example, if you met Category 3 by calling/discussing results, visit documentation, or urgent consultations, you are done. But this is rare; most are with Category 1.

You must meet 3 requirements from Category 1 to qualify. So, let’s dive deeper and clarify these.

  • Review of external notes from each unique source: This is an easy requirement to meet if you’re a specialist because you review the notes to see why patients are referred for treatment. In a PCP office, it can be more limited, hospital discharges and ER visits.
  • Review of unique test results: If you performed an X-ray, for example, and got a WET read, this would count as 1 point. However, you would NOT be able to count the “ordering” of the X-ray itself.
  • Ordering of tests: This requirement is easier to meet for the PCP office. Labs, CMP, LFT, B12, STD, urine dip/cultures, strep test/cultures, flu and Covid tests are just a few examples. Mammography, colonoscopy, and ultrasounds are also included. For clarification, independent historians can be parents, guardians, grandparents, caregivers, group home attendants—or anyone who needs to speak on behalf of the patient or contribute information due to the patient’s age, mental capacity, or disability.

Next week, we will discuss coding by time.


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