Medical decision-making (MDM) considers the work involved to determine a diagnosis and treatment options for the patient, in addition to the amount of data collected and reviewed. Also factored into MDM is the level of risk to the patient, either due to the diagnosis or the management options to treat the diagnosis.
There are four levels of MDM:
- Straightforward
- Low complexity
- Moderate complexity
- High complexity
The 3 Elements of MDM
1. NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS
The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.
Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems.
2. AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED
The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed.
Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test is an indication of the complexity of data being reviewed. On occasion the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or interpretation; this is another indication of the complexity of data being reviewed.
3. RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY AND/OR MORTALITY
The risk of significant complications, morbidity and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s) and the possible management options.
The following table may be used to help determine whether the risk of significant complications, morbidity and/or mortality is minimal, low, moderate or high.
Putting it all Together
The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.
MDM is also considered the most important of the three key components of E&M codes because it reflects the cognitive labor of the provider. This is not to be confused with medical necessity, which is defined by CMS as “service furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition”. While medical necessity and MDM are both important, they are very different concepts. Medical necessity is regarded as the more difficult concept to quantify but is the more important factor when selecting an E/M service level.
Medicare’s Claims Processing Manual section 30.6.1.A, advises, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.”
For more information, please review our Best Practices for E&M History Documentation PowerPoint (click to view).