Coding E and M services |
Coding E/M services

Cracking the Code

Dirk Elston

Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has served on the AMA-CPT Advisory Committee.

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A simple guide to medical decision making (MDM) criteria

I tried to learn the medical decision making criteria, but my head exploded after the second table. Do I really need to learn this stuff?

In a word, yes. You really do need to learn them, but it’s no harder than learning the porphyrias, and you’ll use the knowledge much more often. In fact, you will use it for every patient encounter, every day, for the rest of your career. I recommend that you tape a simplified version of the Medical Decision Making (MDM) criteria to your bathroom mirror and read it every day as you brush your teeth. Or, try them with Grape Nuts at the breakfast table. Gradually, they become second nature and the investment will pay you back for years to come.

MDM depends on the number of diagnoses or treatment options, risk, and amount and complexity of data. Two of the three are required to establish the level of MDM. As dermatologists, we rarely use amount and complexity of data, so my advice is to skip that one and focus on the other two. A patient with an undiagnosed new problem of uncertain prognosis qualifies as moderate medical decision making. We’ll walk through the thought process below, but after you determine the level of MDM, you also need to determine the overall level of service for the visit. When determining the appropriate level of service for a new patient, remember that you need three components (history, physical, and MDM). For an established patient, only two of the three are needed, and MDM is usually the easiest of the three to establish.[pagebreak]

The charts below should allow you to simplify your MDM determinations. There is one important exception: TrailBlazer, the Medicare carrier in Texas, Virginia, Maryland, Delaware, and the District of Columbia, uses an alternate MDM point system. Visit Services/Evaluation and Management/default.aspx for more information about this system.

MDM made simpler

1. Determine severity

The number of diagnoses or treatment options is a simple point system. Two points correlates with low MDM and three points with moderate MDM as long as the level of risk also matches that level.

2. Assign risk level

The level of risk is usually just as easy to establish as the number of diagnoses using the risk table below.

3. Final results for complexity

If both of the above are in the same column, that is your MDM. If they are different, choose the lower of the two.


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MDM made simpler