Definitions and Examples of the Elements of MDM

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Use the tabs below to review the definition of each element of MDM and some examples.

Problem Count/Complexity

Problem Count/Complexity: Definitions and Examples
Problem Status 
Selection in OP
AMA Problem Amount/ComplexityDefinitionExamples
Acute-minorSelf-Limited/MinorA 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-uncomplicatedAcute, uncomplicated illness or injuryA 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-complicatedAcute illness w/ systemic symptomsAn 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

• Pneumonia

Acute-complicatedAcute, complicated injuryAn 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

Acute-complicated
or
Acute-severe
Undiagnosed new problem w/ uncertain prognosisProblem 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-severe
or
Chronic-severe
Acute or chronic illness or injury that poses a threat to life or bodily functionPose 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

Chronic-stable
or
Chronic-recurring
Stable, chronic illnessExpected 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/increasedChronic 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-severeChronic illness w/ severe exacerbationHave significant risk of morbidity and may require hospital level of care.

• Depression w/ suicide ideation

Data Count/Complexity

Data Count/Complexity: Definitions and Examples
Data Count/ComplexityDefinition
TestTests 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 InterpretationTest 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
  • 3 y/o patient: Mom historian, no tests
  • 17 y/o patient: Ordered CBC, comprehensive metabolic panel (outside lab)
  • 9 y/o patient: Ordered strep test, influenza test (in-office)
Moderate
  • 15 y/o patient: Ordered CBC, T4, TSH (outside lab)
  • 2 y/o patient: Spoke w/ Hem-Onc physician to discuss recent labs and course of treatment
  • 6 y/o patient: Reviewed radiologic result from ED and wrote own interpretation
Extensive
  • 3 y/o patient: Dad independent historian, ordered EKG and 2-D Echo, spoke w/ cardiologist about appropriate course for patient
  • 9 y/o patient: Ordered 2 behavioral assessments, spoke w/ both parents as independent historians, spoke w/ referring school counselor regarding initial assessment and plan
  • 12 y/o patient: Mom was historian to discuss black-out episode, independent interpretation of MRI done during ED visit, ordered 3 additional labs

Risk of Complications and/or Morbidity/Mortality

Risk of Complications and/or Morbidity/Mortality: Definitions and Examples
Risk of ComplicationsDefinition
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 toxicityA 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**
  • Supportive care at home, such as: gargle, topical OTC ointment
  • Swab for further lab testing
Low**
  • Blood draw for labs
  • Radiologic tests such as EKGs, x-rays
Moderate
  • New prescription drug for acute condition
  • Ongoing management of chronic condition through prescription management
  • Decision to perform minor surgery (Must be manually adjusted in Coding)
  • Homelessness exacerbating patient's condition (Housing Insecurity; SDoH)
  • Income issues leading to under-dosing a medication (Health Literacy; SDoH)
Extensive**
  • Drug therapy requiring intensive monitoring for toxicity

** OP will not support calculating this Risk Level