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Use the tabs below to review the definition of each element of MDM and some examples.
Problem Count/Complexity: Definitions and Examples
Selection in OP
|AMA Problem Amount/Complexity||Definition||Examples|
|Acute-minor||Self-Limited/Minor||A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.|
• Uncomplicated mosquito bites
• Uncomplicated diaper rash
• Follow-up resolved condition that was low severity
|Acute-uncomplicated||Acute, uncomplicated illness or injury||A recent or new short-term problem w/ low risk of morbidity treatment, and full recovery w/o functional impairment. A problem that is normally self-limited or minor, but is not resolving in a definite and prescribed course.|
• Uncomplicated pharyngitis
• Uncomplicated viral syndrome
• Simple sprain/strain
• Allergic rhinitis
• Allergic conjunctivitis
• Uncomplicated otitis media
|Acute-complicated||Acute illness w/ systemic symptoms||An illness that causes systemic symptoms and has a high risk of morbidity w/o treatment. For systemic general symptoms such as fever, body aches or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness or to prevent complications, (see ‘self-limited or minor’ or ‘acute, uncomplicated.’) Systemic symptoms may not be general, but may be a single system|
• Concussion w/ brief LOC
• Strep throat presenting w/ fever
|Acute-complicated||Acute, complicated injury||An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated w/ risk of morbidity.|
• Injuries resulting from a MVA that include multiple systems
|Undiagnosed new problem w/ uncertain prognosis||Problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity w/o treatment.|
• CBC results w/ high WBCs
• Low RBCs requiring further work-up
|Acute or chronic illness or injury that poses a threat to life or bodily function||Pose a threat to life or bodily function in the near term w/o treatment. Typically, hospital care is needed.|
• Severe respiratory distress
• Renal failure
• Treatment for refractory migraine pain
• New seizure onset
|Stable, chronic illness||Expected duration of at least a year or until death. 'Stable' is defined by the specific treatment goals for an individual patient. A patient that is not at their treatment goal is not stable, even if the condition is unchanged and there is no short-term threat to life or function. Risk of morbidity w/o treatment is significant.|
• Follow-up mild chronic asthma (controlled)
|Chronic-unstable/increased||Chronic illness w/ ...||A chronic illness that is acutely worsening, poorly controlled, or progressing w/ an intent to control progression and requiring additional supportive care or attention to treatment for side effects (excludes hospital care).|
• Worsening headaches/migraines
• Otitis media presenting w/ fever or as recurrent
|Chronic-severe||Chronic illness w/ severe exacerbation||Have significant risk of morbidity and may require hospital level of care.|
• Depression w/ suicide ideation
Data Count/Complexity: Definitions and Examples
|Test||Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (example: basic metabolic panel ) 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.
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.|
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
Risk of Complications and/or Morbidity/Mortality
Risk of Complications and/or Morbidity/Mortality: Definitions and Examples
|Risk of Complications||Definition|
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.
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
** OP will not support calculating this Risk Level