Use the tabs below to review the definition of each element of MDM and some examples.
Problem Count/Complexity
Problem Count/Complexity |
See: At-A-Glance: OP to AMA Problem Status Crosswalk
Data Count/Complexity
Data Count/Complexity: Definitions and Examples |
| Data Count/Complexity | Definition |
| Test | Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (example: basic metabolic panel [80047]) is a single test. The differentiation between single or multiple unique tests is defined in accordance w/ the CPT code set. |
| External physician or other qualified healthcare professional | An external physician or other QHP who is not in the same group practice or is a different specialty or subspecialty. It includes licensed professionals that are practicing independently. It may also be a facility or organizational provider such as a hospital, nursing facility, or home health care agency. |
| Independent historian(s) | An individual (such as: parent, guardian, surrogate, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (due to developmental stage) or because a confirmatory history is judged to be necessary. |
| Independent Interpretation | Test for which there is a CPT code and an interpretation or report is customary. Excludes when the physician or other QHP is reporting the service or has previously reported the service for the patient. Documentation is required, but need not conform to the usual standards of a complete report for the test. |
| Appropriate source | An appropriate source includes professionals who are not health care professionals, but may be involved in the management of the patient (examples: lawyer, case manager, teacher). Excludes discussion w/ family or informal caregivers. |
Examples of MDM Level Based on Data Review | |
| Limited |
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| Moderate |
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| Extensive |
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Risk of Complications and/or Morbidity/Mortality
Risk of Complications and/or Morbidity/Mortality: Definitions and Examples |
| Risk of Complications | Definition |
| Risk | The probability and/or consequences of an event. Definitions of risk are based upon the usual behavior and thought processes of a physician or other QHP in the same specialty. For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment and/or hospitalization. |
| Morbidity | A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment. |
| Social determinants of health | Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity. |
| Drug therapy requiring intensive monitoring for toxicity | A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. Intensive monitoring may be long- or short term. Long-term intensive monitoring is not less than quarterly. The monitoring needs to be a lab test, a physiologic test or imaging. The monitoring affects the level of MDM in an encounter in which it is considered in the management of the patient. |
Examples of MDM Level Based on Risk | |
| Minimal** |
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| Low** |
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| Moderate |
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| Extensive** |
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** OP will not support calculating this Risk Level
