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Crack the Code - Unlocking Higher E/M Levels - Assessing risk of complications for coding

evaluation management mdm — Elements of MDM Map

Medical coding using the three elements of medical decision making (MDM) involves assessing the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications and morbidity or mortality. The three elements are evaluated as follows: Crack the Code - Unlocking Higher E/M Levels - Assessing risk of complications for coding.

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Number and Complexity of Problems Addressed

Minimal (e.g. self-limited or minor problem)
Low (e.g. 2+ self-limited problems, 1 stable chronic illness, 1 acute uncomplicated illness/injury)
Moderate (e.g. 2+ stable chronic illnesses, 1+ chronic illness with exacerbation, 1 undiagnosed new problem, 1 acute illness with systemic symptoms, 1 acute complicated injury)
High (e.g. life-threatening problems, abrupt change in neurologic status)

Amount and Complexity of Data Reviewed and Analyzed

Minimal or none
Limited (e.g. 2+ unique tests/documents/orders)
Moderate (e.g. 3+ unique tests/documents/orders, independent historian, independent interpretation of tests)
Extensive (e.g. review of extensive records, independent historian, independent interpretation of tests, discussion of contradictory or discrepant test results)

Risk of Complications and/or Morbidity or Mortality

Minimal risk
Low risk (e.g. minor surgery with identified patient or procedure risk factors)
Moderate risk (e.g. elective major surgery, emergency major surgery, decision regarding hospitalization)
High risk (e.g. emergency major surgery, decision not to resuscitate or to de-escalate care)

The level of the visit is determined by meeting at least two of the three elements at a given level. Proper coding requires understanding these three interrelated elements of MDM.

The risk of complications and/or morbidity or mortality is one of the three key elements used to determine the level of medical decision making (MDM) for coding evaluation and management (E/M) services. The level of risk is assessed based on the following criteria:

Minimal risk - Presenting problems are self-limited or minor (e.g. cold, insect bite). This qualifies for lower level E/M codes like 99211 or 99212.
Low risk - Minor surgery with identified patient or procedure risk factors, such as obesity, bleeding disorder, uncontrolled diabetes. This supports 99213 or 99203 code levels.
Moderate risk - Elective major surgery, emergency major surgery, decision regarding hospitalization. This meets criteria for 99214 or 99204 codes.
High risk - Emergency major surgery, decision regarding hospice care or not resuscitating. This warrants higher level 99215 or 99205 codes.

The risk element accounts for potential complications and morbidity/mortality associated with the presenting problem(s), diagnostic procedures, possible management options, and future management decisions made at the encounter. Proper assessment of risk is crucial for accurate coding.Importantly, not all conditions arising after a procedure are considered complications for coding purposes. There must be a cause-and-effect relationship between the care provided and the condition, and provider documentation indicating it was a complication. Some expected outcomes of procedures may be inherent risks rather than complications. So in summary, the risk of complications is determined by the provider's medical decision making, the nature of the presenting problems, diagnostic and management options selected, all of which factor into the overall level of MDM and selection of the final E/M code. Crack the Code - Unlocking Higher E/M Levels - Assessing risk of complications for coding.

The three elements of medical decision making (MDM) - number and complexity of problems addressed, amount and complexity of data reviewed and analyzed, and risk of complications and/or morbidity or mortality - are combined to determine the overall level of MDM for a billable patient visit as follows:

Each of the three elements is assessed individually and assigned a level of straightforward, low, moderate, or high complexity based on specific criteria.
The overall level of MDM is then determined by the level met by two or more of the three elements.

For example:

If the problems addressed are moderate, data reviewed is limited (low), and risk is low, the overall MDM level is low.
If the problems are high, data extensive (high), and risk moderate, the overall MDM is high since two elements meet the high level.

The level of MDM (straightforward, low, moderate, high) corresponds to a billable Evaluation and Management (E/M) service code for new or established patients.
When using MDM for code selection, activities related to the encounter like reviewing records or discussing test results can occur on different dates, not just the date of the visit.

So in summary, the three MDM elements are individually assessed, with the two highest levels determining the final overall MDM level which maps to the appropriate billable E/M code for that encounter.

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Here are some examples of how the three elements of medical decision making (MDM) can be combined to determine the overall MDM level and corresponding billable code for a patient visit:

Example 1

Problems Addressed: Moderate (2 stable chronic illnesses)
Data Reviewed: Limited (2 unique tests ordered)
Risk: Low (Minor procedure with identified risk factors)

In this case, two of the three elements meet the "Moderate" level - Problems and Risk. Therefore, the Overall MDM Level is Moderate, which corresponds to a 99214 Established Patient Office Visit code.

Example 2

Problems Addressed: High (Acute life-threatening problem)
Data Reviewed: Extensive (Review of extensive records, discussion of discrepant test results)
Risk: High (Emergency major surgery)

Here, all three elements meet the "High" level of MDM. The Overall MDM is High, which would support billing a 99285 Emergency Department Visit code.

Example 3

Problems Addressed: Low (1 self-limited acute illness)
Data Reviewed: Moderate (3 unique tests, independent historian)
Risk: Moderate (Decision regarding hospitalization)

In this scenario, two elements are at the "Moderate" level - Data and Risk. Therefore, the Overall MDM Level is Moderate, corresponding to a 99213 Established Patient Office code.

Example 4

Problems Addressed: Straightforward (Minor self-limited problem)
Data Reviewed: Minimal
Risk: Low

With two of the three elements at the "Straightforward/Minimal/Low" level, the Overall MDM is Low, which aligns with a 99212 Established Patient Office Visit code.So in each case, the highest two out of the three MDM elements determine the final overall MDM level, which then points to the appropriate billable E/M service code for that encounter based on the combined complexity. Crack the Code - Unlocking Higher E/M Levels - Assessing risk of complications for coding.

What if?

If each of the three medical decision making (MDM) elements - number/complexity of problems, amount/complexity of data, and risk of complications - is at a different level for a single patient visit, then the overall MDM level is determined by the two highest scoring elements.For example:

If the problems addressed are moderate, the data reviewed is extensive (high level), and the risk is low, then the overall MDM level would be moderate since two of the three elements (problems and data) meet that level.
If the problems are high complexity, the data is limited (low level), and the risk is moderate, then the overall MDM is high since the highest two elements (problems and risk) are at the high and moderate levels respectively.
If the problems are low complexity, the data is moderate, and the risk is high, then the overall MDM level is moderate, determined by the two highest scoring elements of data and risk. Crack the Code - Unlocking Higher E/M Levels - Assessing risk of complications for coding

So in summary, when the three MDM elements score differently, the final overall MDM level is based on the two highest scoring elements out of the three. This overall MDM level then correlates to the appropriate billable Evaluation and Management (E/M) service code for that encounter.1 3 5The instructions clearly state that when the three MDM elements differ, the overall MDM and subsequent E/M code selection is determined by the two highest levels met, not an average or middle value of the three individual element levels. Crack the Code - Unlocking Higher E/M Levels - Assessing risk of complications for coding. Crack the Code - Unlocking Higher E/M Levels - Assessing risk of complications for coding.