Finding Patterns of Complexity in the Medical Decision Making (MDM) Table

When the Evaluation and Management (E/M) service codes and guidelines were changed in 2021, the Medical Decision Making (MDM) Table was updated to reflect these changes. In 2023, the MDM Table was updated again but this time to reflect codes, descriptions, and guideline changes specific to facility-based E/M services. To ensure the MDM Table accurately reflects both outpatient and facility-based decision making, several new bulleted items were added.

Contents of the MDM Table

According to the American Medical Association (AMA), the “Current Procedural Terminology (CPT), Fourth Edition, is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians and other qualified health care professionals.”  It also contains definitions for understanding key words, coding guidelines, anatomy and procedure graphics, as well as coding examples. The E/M MDM Table could be considered a cheat sheet provided by the AMA that contains the basic information needed to score an E/M service based on the three MDM elements: 

• Number and Complexity of Problems Addressed at the Encounter
• Amount and/or Complexity of Data to Be Reviewed and Analyzed
• Risk of Complications and/or Morbidity or Mortality of Patient Management 

Patterns Within the MDM Table

When you review the various criteria used to score each element of the MDM Table, it becomes pretty easy to see patterns of complexity within the language used to describe each bulleted item. For example, low, moderate, and high complexity levels contain a mixture of stable and acute conditions, but use different adjectives to describe them at each level of complexity: 

• Low: 
• Stable or uncomplicated problems that just might require hospital-level care.
• Moderate: 
• Multiple stable conditions or acute/chronic conditions that are complicated, progressing, exacerbated, systemic, or have an uncertain prognosis. 
• High: 
• Stable or chronic conditions that are severe (severely exacerbated, severely progressing, or have severe side effects of treatment). These conditions are so severe they may pose a threat of death or loss of bodily function.

Since high complexity E/M encounters tend to be overbilled more than the others, simply asking yourself the following two questions may help in identifying whether or not an E/M encounter meets the criteria of high complexity: 

1. Did the encounter result in hospitalization or emergency, major surgery?
2. Do the documented diagnoses describe an out-of-control acute or chronic condition requiring significant physician/QHP work to bring it under control? Prevent death? Prevent loss of functionality? 

If the answer is no, to either of these questions, then the documentation may not paint a severe enough patient story to warrant assigning a high complexity E/M service code. Attention should be focused on either the problems addressed and data elements met, or in reducing the level of complexity down to a moderate level instead.

Join me for a deep dive into each element of the MDM table where we will discuss the different patterns we see within each MDM element and how we can use the MDM Table to our advantage when analyzing and scoring the E/M encounters. To learn more, click HERE to sign up to attend this free webinar: "Deep Dive into the 2023 Medical Decision Making Table" scheduled for Thursday, August 10, 2023 @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET. Click HERE to register for this FREE webinar.

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