Selecting a level of medical decision-making (MDM) can be confusing and complicated. There are four levels of MDM: straightforward, low, moderate and high. Each level includes three components that, when used together, determine a level of service.
As Tropin relays, within each level, the three components include specific elements required to report that level. The components encompass:
Tropin provides several tips for coders working through MDM selection:
- If two of the three components are at the same level, use that level. For example, if documentation indicates components 1 and 2 are at a low level, it is not necessary to determine a level for component 3 since only two components are needed. In that case use a low level of MDM.
- If each component is at a different level, use the level in the middle. For example, documentation indicates component 1 is straightforward, component 2 is low, and component 3 is moderate. Use a low level (the one in the middle). The coder may round down (from moderate to low risk) but not round up (from low to moderate complexity of data).
- If a single component includes multiple elements at different levels, use the higher level. For example, documentation indicates a patient’s risk (component 3) includes both minor surgery without identified risk (low complexity) and drug management (moderate complexity). Use a moderate level of risk.
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