Selecting a Level of Service based on Medical Decision-Making (MDM) Part I

Monday, May 1, 2023

Time for a refresher on one of two options available to level an evaluation and management (E/M) service. In this next series of three newsletters, we will focus on medical decision-making and its three distinct elements:

  1. Problem: The number and complexity of problems addressed.
  2. Data: Amount and/or complexity of data to be reviewed and analyzed.
  3. Risk: Risk of complications and/or morbidity or mortality of patient management.

When selecting the level of an E/M service, the documentation must meet or exceed two of the three elements (Problem, Data, Risk). The American Medical Association (AMA) provided this document, Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM), on their website to serve as a guide for selecting the appropriate E/M code based on MDM. The code selection should point directly back to the criteria outlined for each code and level.

Element 1

Problem: Select the applicable number and complexity of problems addressed in the encounter. The number and complexity of problems addressed are divided into four levels: minimal, low, moderate, and high. Each level has specific criteria for the conditions addressed. To correctly identify the appropriate level, it is important to understand the “problem” definitions. Clarifying “Problem” Definitions: It is important to understand how different types of illness are defined to correlate them to the appropriate level of MDM and E/M code.

Stable, acute illness: A problem that is new or recent and for which treatment has been initiated. The patient may be improved and stable, but the resolution is not yet complete.

  • Acute, uncomplicated illness or injury requiring hospital inpatient or observation-level care: A recent or new short-term problem with a low risk of morbidity requiring treatment. Treatment requires a hospital inpatient or observation setting.
  • Chronic illness with exacerbation, progression, or side effects of treatment which includes an intent to control the progression and requires additional supportive care or attention to treatment for side effects.

Chronic illness with severe exacerbation, progression, or side effects of treatment: Carries a significant risk of morbidity and may require an escalation in the level of care.

In Part II, we’ll look at data, the second element involved in MDM.

Retrieved 4/27/2023 https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

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