Current E/M
Number and complexity of problems addressed
Number and complexity of problems addressed: In a nutshell
The number and complexity of problems addressed is one of three elements used to determine the level of medical decision making (MDM).
Addressing a problem requires more than asking about the problem and noting it in the patient’s record — you must evaluate or treat the problem.
The nature of problems addressed are categorized into four levels of complexity: minimal or straightforward, low, moderate, and high.
Addressing a problem
Defined as one of the three elements of MDM, the number and complexity of problems presented by the patient require you to ask yourself three questions:
How many problems did the patient bring to my attention?
How many problems did I address?
How complicated is the problem I evaluated or treated?
A problem is considered addressed when it is evaluated or treated by the physician or other qualified non-physician clinician reporting the encounter, including testing or treatment options that were considered but not selected. You cannot include problems that are being managed or addressed by another physician or non-physician clinician without additional work on your part, nor can you include referrals if you do not evaluate the patient or consider the treatment options. In most cases, determining the number and complexity of problems addressed is easier when your patient already has a previously diagnosed problem. This element includes assessing the status of a condition, illness, injury, symptom, sign, finding, complaint, or other matter during the encounter.
Complexity of problems addressed
The reasons patients come to the practice can include a range of problem complexity levels, from minor problems to acute or chronic illness or injury that could pose a threat to life or bodily function. The table below categorizes the different levels of complexity and what is required to reach each level for this element of MDM. The four levels of complexity include straightforward, low, moderate, and high.
A condition may qualify under multiple categories, depending on disease severity and patient presenting circumstances at the time of the encounter. The examples provided do not constitute an exhaustive list. Placement of a condition in a category does not exclude it from other categories.
The Definitions for medical decision-making elements terminology (PDF) provides additional examples on how many dermatologic conditions can be categorized based on complexity and patient presenting circumstances.
| Level of MDM associated with this element (Level of service is based on 2 out of 3 Elements of MDM) | Number and Complexity | Examples |
|---|---|---|
Straightforward |
Minimal • 1 self-limited or minor problem |
|
Low |
Low • 2 or more self-limited or minor problems; or |
|
• 1 stable chronic illness; or |
|
|
• 1 acute, uncomplicated illness or injury |
|
|
Moderate |
Moderate • 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or |
|
• 2 or more stable chronic illnesses; or |
|
|
• 1 undiagnosed new problem with uncertain prognosis; or |
|
|
• 1 acute illness with systemic symptoms; or |
|
|
• 1 acute complicated injury |
|
|
High |
High • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or |
|
• 1 acute or chronic illness or injury that poses a threat to life or bodily function |
|
Now that you have selected the level of the problem(s) addressed, you will need at least one additional MDM element from the list below before determining the overall level of MDM for the encounter:
Amount and/or complexity of data to be reviewed and analyzed; or
Risk of complications, morbidity and/or mortality of patient management
You can also access a list defining the terms used in the table above describing the complexity of the problem addressed (PDF).
Ready to quantify the overall level of MDM? Use the E/M Office Visit Level of MDM Table (PDF) to determine the level of MDM and code for the encounter.
Use the Current E/M coding tool
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