Medical
Decision Making

Effective January 1, 2023, Medical Decision Making (MDM) is the sole determinant of the E/M level of service in the ED. It is essential clinicians fully document their medical decision making in assessing and treating a patient.

3 MDM Components define and score the overall MDM complexity.

2 of the 3 MDM components must be met or exceeded to report the E/M level of service.

Problem - Number and complexity of problems addressed during the encounter

Data - Amount and complexity of data reviewed and analyzed during the encounter

Risk - Risk of complications and/or morbidity or mortality of patient management during the encounter

4 E/M levels of service are provided by clinicians in the ED that are based on MDM*.

* 99281 does not require the presence of a physician or APP nor requires
Medical Decision Making

MDM Scoring Examples

Example 1

Problem = Moderate (Level 4)
Data = High (Level 5)
Risk = High (Level 5)
then MDM Level = High (Level 5, CPT 99285)

Example 2

Problem = Moderate (Level 4)
Data = Minimal (Level 2)
Risk = Low (Level 3)
then MDM Level = Low (Level 3, CPT 99283)

Failure to provide adequate documentation to support one MDM component may result in a decreased overall MDM level and E/M level of service.

Problem Anchor

MDM Problem

The Problem component of the 2023 MDM scoring assesses the number and complexity of problems addressed at the encounter. Specific factors to consider in the MDM Problem component include:

A problem is addressed or managed when it is evaluated or treated during the encounter by the physician / APP reporting the service.

Multiple new and established conditions may be addressed at the same time and may affect the MDM problem level. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice.

The final diagnosis for a condition doesn’t always determine the problem complexity or risk.

Presenting symptoms that may represent a highly morbid condition may “drive” MDM, even when the final diagnosis is not highly morbid. Extensive evaluation may be required to reach the conclusion that the signs or symptoms don’t represent a highly morbid condition.

Comorbidities and underlying diseases are only considered in selecting the level of service if they are addressed during the encounter and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.

If symptoms cluster around a specific diagnosis, each symptom is not necessarily a unique condition.

Risk of condition is distinct from risk of the management of the patient (MDM Component 3)

Problem Types

Self-limited or minor problem

A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.

Examples: Uncomplicated suture removal; uncomplicated wound check; sunburn

Stable, chronic illness

A problem with an expected duration of at least one year or until the death of the patient.

Conditions are treated as “Chronic” whether or not stage or severity changes (e.g., uncontrolled diabetes and controlled diabetes are a single chronic condition).
"Stable" for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.
Examples: Well-controlled hypertension; well-controlled diabetes; cataract(s)

Acute, uncomplicated illness or injury

A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.

A minor traumatic injury or minor illness with no associated systemic symptoms.
Can be evaluated without testing or imaging
Can be usually managed with over-the-counter medications
Examples: Extremity injuries with limited pain, swelling, or bruising; uncomplicated ankle sprain, weight-bearing, no x-ray; allergic rhinitis

Stable, acute illness

A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.

Examples: Impetigo, treatment previously started & condition improving; URI, treatment previously started & improving

Chronic illness with exacerbation, progression, or side effects of treatment

A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects.

Examples: Poorly controlled diabetes and/or diabetes with complications; psych condition with acute episode

Undiagnosed new problem with uncertain prognosis

A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.

Regardless of final diagnosis, accidents and/or injuries that necessitate diagnostic imaging to identify or rule out a clinical condition.
Anything where the presenting symptoms lead to a differential diagnosis that necessitates diagnostic workup or therapeutic intervention.
Examples: New breast lump; new onset leg pain with swelling and/or redness; new onset severe headache, stiff neck, fever

Acute illness with systemic symptoms

An illness that causes systemic symptoms and has a high risk of morbidity without treatment

For systemic general symptoms (such as fever, body aches, or fatigue in a minor illness), see self-limited or minor problem or acute, uncomplicated illness or injury
Systemic symptoms may not be general but may be single system
Examples: Pyelonephritis; pneumonia; respiratory chest pain

Acute, complicated injury

An injury which:

Requires treatment that includes evaluation
of body systems that are not directly part of
the injured organ, or;
the injury is extensive, or
the treatment options are multiple and/or

associated with risk of morbidity

Examples: Head injury with brief loss of consciousness; multiple fractures or other injuries, not life threatening

Chronic illness w/ severe exacerbation, progression, or side effects of treatment

An illness with a severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation of care.

Examples: Poorly controlled diabetes and/or diabetes with severe complications; congestive heart failure with shortness of breath and extremity swelling

Acute or chronic illness or injury that poses a threat to life or bodily function

An illness with systemic symptoms, an acute complicated injury, or chronic illness or injury with exacerbation and/or progression or side effects of treatment that pose a threat to life or bodily function in the near term without treatment

Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function
These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity
Examples: Acute renal failure; unstable angina; hypertensive emergency

Data Anchor

MDM Data

The Data component of the 2023 MDM scoring assesses the amount and complexity of data to be reviewed and analyzed at the encounter. This data includes medical records, tests and/or other information that must be obtained, ordered, reviewed, interpreted and/or analyzed for the encounter.

The data is divided into 3 Categories:

Category 1 - Documents, Tests and Historians

The following 3 elements are combined in the Category 1 counting:

Review of prior external notes per unique source
- Records from an external provider or facility may be counted.
- Notes external to the ED, but from the same facility (from a physician in a different group, specialty or subspecialty) may be counted.
- Notes from same group, same specialty may not be counted
- Past ED records from same facility may not be counted.

Ordering and/or reviewing each unique test
- Ordering and reviewing of the same unique test are not counted separately.
  - Tests ordered are presumed to be reviewed when the results are reported.
  - Tests ordered outside an encounter may be counted during the encounter in which they are reviewed.
- Tests considered, but not ordered, may be counted in Category 1. This consideration must be documented and the reason it was not ordered
- A unique test is defined by the CPT code set. Lab panels count as one test (the individual components of a lab panel are not counted separately).
- Multiple results from same unique tests (serial testing in the same encounter) are counted as a single test.
- For recurring orders, each new result may be counted in the encounter in which it is analyzed (i.e., multiple DOS for inpatient/ outpatient services).
- Any test which is separately billed for the professional interpretation may not be counted (e.g., EKG, point-of-care ultrasound). It may be counted if it is not separately billed.
- Pulse oximetry testing may not be counted in Category 1.

Assessment requiring independent historian
- An independent historian is an individual who provides additional history because the patient is unable to provide a complete or reliable history.
- The history does not need to be obtained in person, but needs to be obtained directly from the historian providing the information.
- If confirmatory history is required, data points for the independent historian may be counted.
- If the independent historian just restates information already provided by the patient, it may not be counted.
- Translation services do not count as an independent historian.
- Examples: Parent, guardian, spouse, care givers, witness or EMS.

Scoring Category 1
- A combination of different data elements allows these elements to be summed when scoring Category 1.
  - Example: Two unique lab tests ordered (2), an external note reviewed (1) and an assessment requiring independent historian (1) would be combined for point resulting in moderate or high complexity of data.
- Assessment requiring an independent historian is a separate category when limited data is identified. It is included in Category 1 scoring for moderate and extensive complexity data only.

Category 2 - Independent Interpretation of Tests

The interpretation of a test for which there is a CPT code and an interpretation or report is customary (e.g. EKG, POCUS, Imaging).

This does not apply when the physician or other qualified health care professional is reporting (billing for) the service or has previously reported the service for the patient.
A form of interpretation should be documented but not need to conform to the usual standards of a complete report.
Example: There is no fracture noted on the x-ray of the right ankle per my interpretation.

Category 3 - Discussion of Management or Test Interpretation

The work performed by the physician / APP in discussion of management or test interpretation with an external physician or other appropriate source.

The discussion of management or test interpretation
- Must be direct and not through intermediaries
- Must be documented in the record
- May be asynchronous
- May be a facility or organizational provider (Hospital, nursing facility or home health agency)
- May be with professionals who are not healthcare professionals but may be involved in the management of the patient (lawyer, parole office, case manager, teacher)
- May not be a member of the same group practice
- May not be a clinician in the same specialty or subspecialty
- May not include discussion with family or informal caregivers

Risk Anchor

MDM Risk

The Risk component of the 2023 MDM scoring assesses the risk of complication and/or morbidity or mortality of the patient addressed at the encounter. Specific factors to consider in the MDM Risk component include:

Assessment of the level of risk is affected by the nature of the event under consideration.

Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities).
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.
The risk of patient management criteria applies to the patient management decisions made by the reporting physician / APP as part of the reported encounter.

Prescription drug management is based on documentation the physician / APP has administered, prescribed, or evaluated current medications during the ED visit.

This may be any administration of prescription strength medication while the patient is in the ED, a prescription written to be filled at the pharmacy, discontinuation or modifications to the patient’s existing medication dosages, or after consideration of the current medications, the decision to maintain the current medication regimen.

Social determinants of health (SDOH) include any economic or social condition such as food or housing insecurity that may significantly limit the diagnosis or treatment of a patient’s condition (e.g., inability to afford prescribed medications, unavailability, or inaccessibility of healthcare).

The mere presence of an issue is not the determining factor. The issue must significantly limit the diagnosis or treatment.
The documentation should indicate how the SDOH was relevant to the diagnosis and treatment of the patient through one of the mechanisms addressed above.
Examples of SDOH in the ED include: Homelessness/undomiciled, unemployed, illiteracy, relationship involving emotional/physical abuse, uninsured, and alcohol or polysubstance abuse.

Classification of minor and major surgeries is based upon the common meaning of such terms when used by trained clinicians. Risk factors are those that are relevant to the patient and procedure

Decision regarding hospitalization or escalation of hospital-level care involves consideration of an escalation of care beyond the ED, such as Observation or Inpatient status or transferring a patient to another facility for continuing of care (e.g. trauma center, psychiatric hospital, burn center, etc.). The determination of risk also includes decision making when the outcome is to forego further testing, treatment, and/or hospitalization.

Risk Level Examples:

More Resources

2023 E/M Overview

What's

Changing?

Think in Ink!

Documentation Best Practices

Practical

Examples

Videos on Common Encounters

Medical Decision Making

2023 MDM Scoring

Other

Resources

Additional

Topics