Evaluation and management codes

Here’s why you actually need to understand MDM

In simple terms, Medical Decision Making is how difficult it is to figure out what is going on with your patient, and how you’re going to treat that condition. 

You will use MDM with every single patient encounter. Every day. For the rest of your career. So, it’s pretty deep. 

MDM is one of the three components that go into correctly coding the levels of evaluation and management (E/M) services provided to your patients. Basically, it’s impossible to correctly document and code E/M services without nailing down the MDM. 

That might sound a bit overwhelming at first. But once you get the hang of it, it becomes second-nature, like recognizing a suspicious mole or washing your hands. 

The elements of MDM

You will need to identify two of these three factors to establish the level of MDM:

1. Number of possible diagnoses or treatment options

2. Risk of complications, morbidity, mortality, or comorbidities

3. Amount and complexity of data (information taken from sources such as lab tests, imaging, or old medical records)

Dermatologists don’t often use “amount and complexity of data,” so you might want to put that one on the backburner and focus specifically on the other two.

Number of possible diagnoses or treatment options

To figure out possible diagnoses and treatment options, ask yourself these five questions:

1. How many problems did the patient and I talk about?

2. How certain am I of the diagnosis?

3. How many treatment and management options can I offer?

4. How certain am I of which treatment or management option to use?

5. Did I have to seek advice from others about the diagnosis or treatment?

In most cases, medical decision making is easier when your patient already has a diagnosed problem. It’s also easier when a problem is resolving or improving instead of getting worse or not responding to treatment as expected. 

Risk of complications, morbidity, mortality, or comorbidities

Risk doesn’t just refer to risks associated with the actual condition. It also includes the risks of the diagnostic procedures or treatment options. If treatment requires a common medication, the risk level in the MDM will probably be much lower than it would be if treatment requires an invasive surgery.

Reviewing the urgency of a procedure can also be useful in determining the risk, so make sure to include that in your documentation. 

Amount and complexity of data

While you probably won’t use this one as much, it’s helpful to be familiar with the basics. If you do decide to use this as one of your MDM factors, be sure to document:

• Your reasons for ordering diagnostic testing or ancillary services, as well as why you consulted older medical records

• Whether you had to consult with others providers on making a diagnosis or determining treatment options

• Relevant findings from old medical records

• Review of diagnostic test results, such as elevated white blood cell counts

• Your interpretation of images, tracings, or specimens that have been, or will need to be, interpreted by another physician

Put it all together

So you have all of this data, but what do you do with it?

Take a look at this table:

Two of the three elements for each type of decision making need to be met or exceeded to meet that qualification. 

• If your number of possible diagnoses is limited, and the risk is low, then the MDM can be considered “low complexity.”

• If the number of possible diagnoses is limited, but the risk is high, the MDM is still “low complexity.” Even though the risk is high, it is the only element to have met and/or exceeded “high complexity.” However, both elements have met and/or exceeded “low complexity,” which is why it’s still considered low.  

Test your knowledge

You can test your knowledge of E/M coding by taking a short Academy quiz, or see other coding quizzes.

Related Academy resources