MDM Guidelines

# and Complexity of Problems Addressed

 

The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter. For each encounter, an assessment, clinical impression, or diagnosis should be documented as well as decisions regarding management plans and/or further evaluation. 

NOTE:  The descriptions and guidance for this element of MDM change on January 1, 2021

Grade

2021 and Beyond

2020 and Earlier

Minimal

  • 1 self-limited or minor problem

  • 1 diagnosis or management option (e.g., Reassured patient)

Low / Limited

  • 2 or more self-limited or minor problems; OR

  • 1 stable chronic illness; OR 

  • 1 acute, uncomplicated illness or injury

  • 2 diagnoses and/or management options (e.g., Cataract, Follow up in six months)

Moderate / Multiple

  • 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

  • 3 diagnoses and/or management options (e.g., Cataract, Glare Testing in 3 months; Floaters)

High Extensive

  • 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 

  • 4 or more diagnoses and/ or management options (e.g., Cataract, Glare Testing 3 months, new glasses; Floaters, Dilated vitreoretinal assessment 6 months)

Amount and Complexity of Data to be Reviewed and Analyzed 

The amount and/or complexity of data to be reviewed is based on the types of diagnostic testing ordered and reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed. Discussion of contradictory or unexpected test results is an indication of complexity. Reviewing a test report or interpretation is another indication of complexity. 

NOTE:  The descriptions and guidance for this element of MDM change on January 1, 2021 

Grade

2021 and Beyond

2020 and Earlier

Minimal

  • Minimal or none

  • no significant record review and minimal diagnostic testing review

Limited

(must meet the requirements of at least 1 of the 2 categories) 
Category 1: Tests and documents 

  • Any Combination of 2 from 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

or 
Category 2: Assessment requiring an independent historian(s) 
(For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high)  

  • limited record review and/or limited diagnostic testing review

Moderate

(must meet the requirements of at least 1 out of 3 categories) 
Category 1: Tests, documents, or independent historian(s) 

  • Any combination of 2 from 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 with external physician/other qualified health care professionalappropriate source (not separately reported)

  • moderate record review and/or moderate diagnostic testing 
    review

Extensive

(must meet the requirements of at least 2 out of 3 categories) 
Category 1: Tests, documents, or independent historian(s) 

  • Any combination of 3 from 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 with external physician/other qualified health care professionalappropriate source (not separately reported)

  • extensive record review and/or extensive diagnostic testing review

Risk of Complications 

The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), diagnostic procedure(s), and possible management options. 

NOTE:  The descriptions and guidance for this element of MDM change on January 1, 2021 

Grade

2021 and Beyond

2020 and Earlier

Minimal

  • Minimal risk of morbidity from additional diagnostic testing or treatment

  • one self-limited or minor problem (e.g. viral conjunctivitis, subconjunctival hemorrhage, floaters, migraine aura) 

Low

  • Low risk of morbidity from additional diagnostic testing or treatment

  • two or more self-limited or minor illness; one stable or chronic illness; one acute illness or injury; acute uncomplicated injury or illness (e.g., minor cataract, corneal abrasion, PVD, treated retinal hole, amblyopia, blepharitis; or combination of two lesser self-limited ocular problems)

Moderate

Moderate risk of morbidity from additional diagnostic testing or treatment  

  • Examples only:

  • Prescription drug management

  • Decision regarding minor surgery with identified patient or procedure risk factors

  • Decision regarding elective major surgery without identified patient or procedure risk factors

  • Diagnosis or treatment significantly limited by social determinants of health

  • One chronic illness with mild complication(s); Two stable chronic illnesses; An undiagnosed new problem (uncertain prognosis); Acute illness with systemic symptoms; Acute complicated injury (e.g. strabismus and amblyopia of moderate degree, early AMD, advancing cataract, non-proliferative diabetic retinopathy, glaucoma without advanced field loss, loss of vision or visual ability, suspected multiple sclerosis, suspected diabetes with myopic shift, lid laceration, iritis; or combinations of two lesser and chronic ocular problems) 

High

High risk of morbidity from additional diagnostic testing or treatment

  • Examples only:

  • Drug therapy requiring intensive monitoring for toxicity 

  • Decision regarding elective major surgery with identified patient or procedure risk factors

  • Decision regarding emergency major surgery 

  • Decision regarding hospitalization

  • Decision not to resuscitate or to de-escalate care because of poor prognosis

  • One or more chronic illness with severe complications; Acute or chronic illness or injuries posing a threat to life; Abrupt change in neurological status (e.g., cataract, glaucoma, or AMD with advanced vision loss, CRAO/fleeting blindness, proliferative diabetic retinopathy, choroidal melanoma)