Levels of Medical Decision Making

Question 1

MEDICAL DECISION MAKING

Answer 1

MEDICAL DECISION MAKING
Otherwise known as MDM

According to the American Medical Association (AMA) Medical Decision Making (MDM) is the Process in which the Physician or Other Qualified Healthcare Professional Establishes a Diagnosis, Evaluates the status of a condition, and/or Selects a Management Option.

Four Types/Categories:
Straightforward, Low, Moderate, High

Question 2

SELECTION OF CATEGORIES FOR E/M SERVICES:

1.Outpatient
2.Home Health Services
3.Nursing Facility Care
4. Inpatient
5. Observation

Answer 2

Based on Either Medical Decision Making (MDM) with an:
1. Appropriate History Intake and
Examination
or
2. Time (WITH THE EXCEPTION OF EMERGENCY SERVICES CODING)

Question 3

MDM: SELECTION PROCESS

Answer 3

MDM: SELECTION PROCESS

TWO OF THREE for that TYPE/CATEGORY MUST BE MET OR EXCEEDED

1. PROBLEM
   Number and Complexity of Problem(s) that are Addressed
2. DATA
   Amount and/or Complexity of Data to be Reviewed and Analyzed, including: Tests, Medical Records, Communication with an Independent Historian or Healthcare Professional
3. RISK OF COMPLICATIONS AND/OR MORBIDITY OR MORTALITY OF PATIENT MANAGEMENT
   Risk of Complications and/or Morbidity or Mortality of Patient Management Associated with a Diagnostic Procedure or Treatment (Even IF NOT Selected by the Patient)

Question 4

MDM SELECTION:

Step 1: PROBLEM

          Minimal

Answer 4

*Minimal Problem:

A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211, 99281)

Question 5

MDM SELECTION:

Step 1: PROBLEM

    Self-Limited or Minor

Answer 5

*Self-Limited or Minor Problem:

A problem that runs a definite and prescribed course, is transient
in nature, and is not likely to permanently alter health status

Question 6

MDM SELECTION:

Step 1: PROBLEM

          Stable, Chronic Illness

Answer 6

*Stable, Chronic Illness

Conditions are treated as chronic
whether or not stage or severity changes [eg, uncontrolled diabetes and controlled diabetes are a single chronic condition].

“Stable” for the purposes of categorizing MDM is defined by the
specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable.

For example, a patient with persistently poorly controlled blood pressure for whom
better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.

Question 7

MDM SELECTION:

Step 1: PROBLEM

Acute, Uncomplicated Illness or Injury

Answer 7

*Acute, Uncomplicated Illness or Injury:

A recent or new short-term problem with low risk of morbidity for which treatment is considered.

There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.

A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course.

Question 8

MDM SELECTION:

Step 1: PROBLEM

Acute, uncomplicated illness or injury Requiring Hospital Inpatient or Observation Level Care

Answer 8

*Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care

A recent or new short-term problem with low risk of morbidity for which treatment is required.

There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.

The treatment required is delivered in a hospital inpatient or observation level setting.

Question 9

MDM SELECTION:

Step 1: PROBLEM

Stable, acute illness

Answer 9

*Stable, acute illness:

A problem that is new or recent for which treatment has been initiated.

The patient is improved and, while resolution may not be complete, is stable with respect to this condition.

Question 10

MDM SELECTION:

Step 1: PROBLEM

Chronic illness with exacerbation, progression, or side effects of treatment

Answer 10

Chronic illness with exacerbation, progression, or side effects of treatment

The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care

Question 11

MDM SELECTION:

Step 1: PROBLEM

Undiagnosed new problem with uncertain prognosis

Answer 11

Undiagnosed new problem with uncertain prognosis

A problem in the differential diagnosis
that represents a condition likely to result in a high risk of morbidity without treatment.

Question 12

MDM SELECTION:

Step 1: PROBLEM

Acute illness with systemic symptoms

Answer 12

*Acute illness with systemic symptoms

An illness that causes systemic symptoms and has a high risk of morbidity without treatment.

For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see the definitions for
self-limited or minor problem or acute, uncomplicated illness or injury.

Systemic symptoms may not be general but may be single system.

Question 13

MDM SELECTION:

Step 1: PROBLEM

Acute, complicated injury

Answer 13

Acute, complicated injury

An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment
options are multiple and/or associated with risk of morbidity.

Question 14

MDM SELECTION:

Step 1: PROBLEM

Chronic illness with severe exacerbation, progression, or side effects of treatment

Answer 14

Chronic illness with severe exacerbation, progression, or side effects of treatment

The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.

Question 15

MDM SELECTION:

Step 1: PROBLEM

Acute or chronic illness or injury that poses a threat to life or bodily function

Answer 15

Acute or chronic illness or injury that poses a threat to life or bodily function

An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment.

Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function.

These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity

Question 16

LEVEL OF MDM:
STRAIGHTFORWARD

Answer 16

LEVEL OF MDM: STRAIGHTFORWARD

Codes: 99202, 99212, 99221, 99231, 99234, 99242, 99252

PROBLEM: Minimal

1 self-limited or minor problem

DATA: Minimal or None

RISK OF COMPLICATIONS
AND/OR MORBIDITY OR MORTALITY OF PATIENT MANAGEMENT: Minimal

Minimal risk of morbidity from additional diagnostic testing or treatment

Question 17

LEVEL OF MDM:
LOW

Answer 17

LEVEL OF MDM:
LOW

Codes: 99203, 99213, 99221, 99231, 99234, 99243, 99253

PROBLEMS: Low

2 or more self-limited or minor problems OR

1 stable chronic illness OR

1 acute, uncomplicated illness or injury OR

1 stable acute illness OR

1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care

DATA: Low
(Must Meet At Least 1 of 2 Categories)

Category 1: Tests and Documents At Least 2 of the following:
*Review of prior external note(s) from each unique source
*Review of the result(s) from each unique test
*Ordering of each unique test
OR
Category 2: Assessment requiring an independent historian(s)

RISK OF COMPLICATIONS AND/OR MORBIDITY OR MORTALITY OF PATIENT MANAGEMENT: Low

Low risk of morbidity from additional diagnostic testing or treatment

Question 18

LEVEL OF MDM:
MODERATE

Answer 18

LEVEL OF MDM:
MODERATE

Codes: 99204, 99214, 99222, 99232, 99235, 99244, 99254

PROBLEMS: 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

DATA: Moderate
(Must Meet At Least 1 out of 3 Categories)

CATEGORY 1: Tests, documents, or independent historian(s)

Any Combination of Any 3 of the Following:

• Review of prior external note(s) from each unique source
  *Review of the result(s) of each unique test
  *Ordering of each unique test
  *Assessment requiring an independent historian(s)

OR

CATEGORY 2: Independent Interpretation of Tests

*Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)

OR

CATEGORY 3: Discussion of Management or Test Interpretation

*Discussion of management or test interpretation physician/other qualified health care professional/appropriate source (not separately reported)

RISK OF COMPLICATIONS AND/OR MORBIDITY OR MORTALITY OF PATIENT MANAGEMENT: Moderate

Moderate risk of morbidity from additional diagnostic testing or treatment.

Examples:
*Prescription drug management
*Decision regarding minor surgery with identified risk factors
*Decision regarding elective major surgey without identified risk factors
*Social determinants of health affecting diagnosis or treatment

Question 19

LEVEL OF MDM:
HIGH

Answer 19

Codes: 99205, 99215, 99223, 99233, 99236, 99245, 99255

PROBLEMS: 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

DATA: High
(Must Meet at Least 2 out of 3 Categories)

Category 1: tests, documents, or independent historian(s)

Any combination of 3 of the following:

*Review of the result(s) of each unique test
*Ordering of each unique test
*Ordering of each unique test
*Assessment requiring an independent historian(s)

OR

Category 2: Independent interpretation of tests

*Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)

OR

Category 3: Discussion of management or test interpretation

*Discussion of management or test interpretation with external physician/other health care professional/appropriate source (not separately reported)

RISK OF COMPLICATIONS AND/OR MORBIDITY OR MORTALITY OF PATIENT MANAGEMENT: High

High risk of morbidity from additional diagnostic testing or treatment.

Examples:
*Drug therapy requiring intensive monitoring for toxicity

*Decision regarding major elective surgery with identified risk factors

*Decision regarding emergency major surgery

*Decision regarding hospitalization or escalation of hospital-level care

*Decision not to resuscitate or de-escalate care due to poor prognosis

*Parenteral controlled substances

Question 20

MDM SELECTION:

Step 1: PROBLEM

Risk

Answer 20

MDM SELECTION:

Step 1: PROBLEM

Risk

The Probability and/or Consequences Of an Event

*
*
*

Question 21

MDM SELECTION:

Step 1: PROBLEM

Important Considerations:

Answer 21

*Important Considerations

Question 22

Step 3: RISK OF COMPLICATIONS AND/OR MORTALITY OF PATIENT MANAGEMENT:

Risk

Answer 22

*Risk

Relates to Risk From the Condition

Question 23

Step 1: PROBLEM
Select the applicable number and complexity of problems addressed at the encounter:

Problem

Answer 23

*Problem

A Disease, Condition, Illness, Injury, Symptom, Sign, Finding, Complaint, or Other Matter Addressed at the Encounter, With or Without a Diagnosis Being Established at the Time of the Encounter

Question 24

Step 1: PROBLEM
Select the applicable number and complexity of problems addressed at the encounter:

Problem Addressed

Answer 24

*Problem Addressed

When a Problem is Evaluated or Treated at the Encounter By the Physician or Other Qualified Health Care Professional Reporting the Service

Question 25

MDM SELECTION

Step 3:
RISK OF COMPLICATIONS AND/OR MORTALITY OF PATIENT MANAGEMENT:
Morbidity

Answer 25

Morbidity

A State of Illness or Functional Impairment that is Expected to be of Substantial Duration During Which Function is Limited, Quality of Life is Impaired, or There is Organ Damage that May Not be Transient Despite Treatment.

Question 26

MDM SELECTION

Step 3:
RISK OF COMPLICATIONS AND/OR MORTALITY OF PATIENT MANAGEMENT:

Social Determinants of Health

Answer 26

Social Determinants of Health

Economic and Social Conditions that Influence the health of all people and communities.

Examples: Food or Housing Insecurity.

Question 27

MDM SELECTION

Step 3:
RISK OF COMPLICATIONS AND/OR MORTALITY OF PATIENT MANAGEMENT:

Surgery (minor or major, elective, emergency, procedure or patient risk)

Answer 27

Surgery (minor or major, elective, emergency, procedure or patient risk)

Surgery–Minor or Major: classification is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification.

Surgery–Elective or Emergency: describe the timing of a procedure when the timing is related to the patient’s condition. An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.

Surgery–Risk Factors, Patient or Procedure: Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.

Question 28

MDM SELECTION

Step 3:
RISK OF COMPLICATIONS AND/OR MORTALITY OF PATIENT MANAGEMENT:

Drug therapy requiring intensive monitoring for toxicity

Answer 28

Drug therapy requiring intensive monitoring for toxicity:

Question 29

MDM SELECTION

Guidelines for Selecting Level of Service Based on Time

Answer 29

MDM SELECTION

Guidelines for Selecting Level of Service Based on Time

Question 30

MDM SELECTION

Unlisted Service

Answer 30

Unlisted Service

An E/M Service may be provided that is not listed in this section of the CPT codebook.

When reporting such a service, the appropriate unlisted code may be used to indicate the service, identifying it by “Special Report.”

The “Unlisted Services” and accompanying codes for the E/M section are:

99429 Unlisted Preventive Medicine Service

99499 Unlisted Evaluation and Management Service

Question 31

MDM SELECTION

Role of Time in E/M Procedures (1)

Answer 31

According to the American Medical Association (AMA):

*Both FACE-TO-FACE TIME spent with: Patient, Guardian, or Family Members AND NON-FACE-TO-FACE TIME Personally Spent by the physician or other qualified healthcare provider on the day of the encounter SHOULD BE ACCOUNTED FOR when selecting a level for a E/M service.

Question 32

MDM SELECTION

Role of Time in E/M Procedures (2)

Answer 32

According to the American Medical Association (AMA) For Services:

*55 MINUTES OR LONGER:
Prolonged Services code 99417 IN CONJUCTION with:
CPT codes: 99205, 99215, 99245, 99345, 99350, 99483

Question 33

MDM SELECTION

Role of Time in E/M Procedures (3)

Answer 33

According to the American Medical Association (AMA) For Services:

• If in a OUTPATIENT SETTING:
  TIME SPENT SUPERVISING CLINICAL STAFF WHO ARE EVALUATING PATIENTS ONLY use CPT Code: 99211 (it does not require any specific key component requirements like 99212–requires two of three components)

Question 34

MDM SELECTION

Role of Time in E/M Procedures (4)

Answer 34

According to the American Medical Association (AMA) For Services:

*Because a Physician Working in the Emergency Department MAY MANAGE MULTIPLE PATIENTS OVER AN EXTENDED PERIOD OF TIME:
EMERGENCY SERVICES CPT Codes (99281-99285) CANNOT BE REPORTED BASED ON TIME