Medical Decision-Making (MDM) can be a complex and confusing process for medical coders. However, by understanding key concepts and following a simplified system, coders can accurately determine the appropriate MDM level for a given case. This article breaks down MDM and its components, providing a clear guide to help coders make more informed decisions.
What is Medical Decision-Making (MDM)?
MDM refers to the provider’s thought process when determining a diagnosis, selecting a treatment plan, or making decisions related to patient management. It does not involve the physical examination of a patient (such as touching or examining body areas), although the patient’s history and examination may be included in the code description. However, the history and examination do not directly influence the MDM level.
CPT Codes that Include MDM
MDM is involved in a range of CPT codes, including but not limited to:
- Synchronous audio-video and audio-only services: 98000-98015
- Office or outpatient services: 99202-99205, 99212-99215
- Hospital inpatient or observation care: 99221-99223, 99231-99236
- Consultations: 99242-99245, 99252-99255
- Emergency department services: 99282-99285
- Nursing facility services: 99304-99310
- Home or residence services: 99341-99350
- Cognitive assessment and care plan services: 99483
- Chronic care management: 99487-99489
- Transitional care management services: 99495-99496
Levels of MDM
MDM is categorized into four levels:
- Straightforward
- Low
- Moderate
- High
Each level is determined by three main components. The combination of these components determines the appropriate level of service.
Component 1: Number and Complexity of Problems Addressed
This component evaluates the severity and number of problems the provider addresses in the patient’s care. The level of complexity is based on the condition’s severity, even if the final diagnosis is not severe.
Definitions of Problem Complexity:
- Self-limited/minor: A condition with low risk (e.g., a simple rash).
- Stable: A chronic condition where treatment is effective, but untreated conditions may lead to significant morbidity.
- Unstable: A condition that is worsening, poorly controlled, or complicated by other factors (e.g., treatment side effects).
- Complicated: A condition with uncertain prognosis or systemic symptoms that requires careful management.
- New, undiagnosed problem: A condition under differential diagnosis that may involve a high risk of morbidity if left untreated.
MDM Levels Based on Problem Complexity:
- Self-limited or minor problems:
- One problem = Straightforward
- Two or more problems = Low
- Stable or uncomplicated problems (chronic or acute):
- One problem = Low
- Two problems = Moderate
- Unstable or complicated problems (acute or chronic):
- Moderate risk = Moderate level
- Severe, life-threatening risk = High level
Component 2: Amount and Complexity of Data to Be Reviewed
This component involves the data gathered, ordered, or analyzed in determining a diagnosis or treatment plan for the patient. The more extensive and complex the data, the higher the level of MDM.
Key Terms for This Component:
- Data: Includes medical records, test results, and other patient-related information.
- Analyze: The process of using data to make clinical decisions.
- Review: A simple look over results (e.g., reviewing test results).
- Interpretation: In-depth analysis of test results or clinical data.
- Independent Historian: A person who provides additional history information (e.g., family member or caregiver).
System for Categorizing Data Complexity:
- Low level: Two points for reviewing, ordering, or interpreting separate tests or notes, or reviewing information from an independent historian.
- Moderate level: Three points for reviewing, ordering, or interpreting tests, or for discussing management options with an independent historian.
- High level: Requires three points for reviewing tests or discussing management options and includes independent interpretation of tests by another provider.
Component 3: Risk of Complications or Mortality
This component assesses the risks involved with managing a patient’s condition, including possible complications, morbidity, or mortality related to treatment or further diagnostic testing.
Key Terms for This Component:
- Risk: The potential negative outcomes from treatment or diagnostic procedures.
- Identified risk factors: Conditions like diabetes, age, or surgery-related factors that increase the likelihood of complications.
- Drug management: Managing medications, including prescribing new drugs or altering existing prescriptions.
- Intensive monitoring for drug toxicity: Closely monitoring a drug that could have severe side effects.
Levels of Risk:
- Low risk: Minimal risk related to treatment or management decisions.
- Moderate risk: Decisions that may involve hospitalization, minor surgery, or reviewing prescriptions.
- High risk: Decisions involving major surgery, life-threatening conditions, or high-risk drug management.
Determining the MDM Level
The final MDM level is determined by combining the evaluations from the three components:
- If two components are at the same level, use that level (e.g., if components 1 and 2 are both moderate, the final MDM level is moderate).
- If each component is at a different level, choose the middle level (e.g., if component 1 is straightforward, component 2 is low, and component 3 is moderate, the final level is low).
- If multiple elements in a component are at different levels, use the higher level (e.g., if risk includes both minor surgery and drug management, use moderate risk).
Conclusion
MDM can be challenging due to its detailed definitions and multiple options. However, by following this structured approach—using points and clear definitions—coders can determine the appropriate MDM level more accurately and efficiently. Understanding these components and their complexities is essential to ensure that medical decisions are coded correctly and reflect the level of care provided to patients.