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Doc/Coding tips

Medical Decision Making
Posted: June 15, 2018

It’s undoubtedly not a surprise to know that each encounter you provide involves some degree of medical decision making.  From establishing a diagnosis to ordering tests to initiating a care plan, much of what takes place in an encounter involves your medical expertise.  Did you know that quantifying that degree of decision making is a key consideration when coding an encounter from the 99xxx series?

Remember that the evaluation and management codes (99201-99205 for new patients and 99211-99215 for established) are based on consideration of three components: case history, physical exam, and medical decision making (MDM).  An encounter with a new patient must consider all three components to be coded properly while an encounter with an established patient only needs to consider two.

It’s that last fact coupled with a general misunderstanding of how to grade MDM that leads many to say “I’m not going to worry about it”.  And while that approach will never lead to over-coding a visit, it could result in under-coding one.  So let’s explore MDM a bit further.  As we do, keep in mind that grading MDM is not hard.  But as with anything “new”, it’ll take a little bit of time to develop comfort with it.

Fact 1:  MDM can be “graded” one of four ways:

  • Straightforward
  • Low Complexity
  • Moderate Complexity
  • High Complexity

Fact 2:  The grading of MDM depends on consideration of the following elements:

  • # of diagnoses and management options
  • Amount and complexity of data
  • Risk

Fact 3:  Only two of the three elements must be considered to grade the MDM

Fact 4:  Two elements, “# of diagnoses and management options” and “Risk”, are easily quantifiable.  “Amount and complexity of data” is more subjective and, in turn, a little bit harder to support in an audit.  Thus, if only two elements are required to grade MDM, it makes sense to focus on the two that are most easily defined and supported.

Let’s stop there for a second to recap and restate.  MDM depends on the grading of two elements and we’re going to focus on the two that are easiest to determine and support if questioned:

  • # of diagnoses and management options
  • Risk

Still on board?  Great!  Let’s take a look at both of those elements independently.

# of diagnoses and management options

Just as the title suggests, this is a simple count of the number of diagnoses and management options that resulted from the visit.  Here’s an example from RevolutionEHR:

We can see that the patient had one diagnosis assessed and that diagnosis carried two management options.  1+2=3.  Easy, right?  To grade this element, then, we’d use a system like below to determine that this element equaled “limited”:

Why the phrasing “We’d use a system like below” rather than be more definitive?  Because the gold standard reference document, the 1997 Documentation Guidelines for the Evaluation and Management Services (which you can find through the Help menu in RevolutionEHR), is ambiguous in this area.  Thus, it’s important that each doctor develops a level of comfort with a system and be consistent with its application.  The above system was used for decades by Dr. Chuck Brownlow in his medical record reviews and if it’s good enough for him, it’s worth our attention and consideration.

Here’s another example of a more complex case where the doctor is managing glaucoma, AMD, and diabetes during the same visit:

In this example, we have three diagnoses and eight management options totaling 11 making this element “extensive”:

Please note:

  • Quantification here is not related to the number of line items in the care plan.  In the examples above, the doctor could have listed everything for each diagnosis in one line item and the total still would have been as we calculated.  It’s purely a matter of how many diagnoses there were plus the number of management options.


  • Only those diagnoses relevant to the RFV should be counted when grading this element.  If the patient was being seen for an “itchy right eye”, for example, and also had diagnoses of diabetes and macular degeneration as part of the assessment, those would not be counted UNLESS they influenced the care related to the RFV in some way.

And that’s how the # of diagnoses and management options is determined.  We’re already half way done!  Let’s move on to a discussion of risk.


The most important thing to understand about the risk element is that it’s not based on your subjective assessment of how tough the case is.  An encounter with a patient with well-controlled glaucoma, early cataracts, and dry eye is not deemed “low” risk just because you believe the case to be easy to manage.

Instead, the documentation guidelines provide a framework to help quantify risk (the first two columns are “official” while the last column is a list we created to provide examples of the descriptions. Click image to make bigger):

The point made earlier should become evident as you look at this table: grading of risk is not a matter of your feelings about the case.  As an example, our earlier case in the section above involving well-controlled forms POAG, AMD, and diabetes would be considered “moderate” in risk even though all three might be on “cruise control” management-wise.

Putting it all together 

Now that you have both the # of diagnoses and management options and risk graded, what do you do with that information?  How do those two pieces of information lead to overall grading of MDM?   To answer that let’s look at a table summarizing how grading of the elements described above translate to an overall MDM grade:

The shaded row at the top of the chart represents the final MDM grade while the rows below represent the grading of each of the two MDM elements we discussed.  To determine the final MDM grade, we simply choose the column containing the lowest graded element.

As an example, if your encounter with a patient involved “multiple” # of diagnoses and management options and “low” risk, the final MDM grade would be “Low Complexity”:

As another example, if the grading of # of diagnoses and management options and Risk were in the same column, you’d simply choose that column for the final grading:

Let’s do one last example, but this time starting at the very beginning of the encounter.  This visit was initiated by the doctor’s order at the conclusion of the previous visit and as part of the case history the patient notes a new complaint:

As unrealistic as it might be under this scenario, let’s say that refractive status was also evaluated during the course of the visit ultimately leading the doctor to three diagnoses in the assessment and plan:

To grade the MDM, we now need to consider the two elements we discussed: # of diagnoses and management options and risk.

Step 1: # of diagnoses and management options

It’s easy to see how dry eye and allergic conjunctivitis were pertinent to the stated reasons for visit, but the patient’s refractive status had no relationship to those reasons.  Thus, even though there are three diagnoses listed in the assessment, we will only count the two that were pertinent.

For management options, we’ll also only count those related to the two pertinent diagnoses.  There are three of those.

2 diagnoses + 3 management options = 5 = “multiple”

Step 2: Risk

Dry eye and chronic allergic conjunctivitis could be best described as “two stable chronic illnesses” = “moderate” risk

Step 3: Grade Final MDM

“Multiple” diagnoses and management options coupled with “moderate” risk means the MDM for this case could best be categorized as “moderate complexity”:

This example highlights what we discussed earlier regarding MDM not being reflective of your personal opinion of the case.  If it was, it’s highly unlikely that you’d categorize the management of stable allergic conjunctivitis and dry eye as “moderate complexity”.  However, this example illustrates how that could be true.

The good news about the final MDM grading is that if you didn’t want to commit that table to memory, you don’t have to.  The auto-coding system in RevolutionEHR can do that work for you.  Specifically, the MDM screen can and should be added to your encounters to help you with the final determination. 

Most will include the MDM screen near the bottom of the Assessment and Plan step like this:

From there, the MDM screen allows you to enter the grades you’ve determined for the # of diagnoses and management options and risk:

Using the last example above, we’ll enter “Multiple” and “Moderate” respectively:

When we then select “Auto-code Preview” on the Coding screen, RevolutionEHR will grade the final MDM:

What’s more is that it will take the final MDM grading into consideration alongside the case history and physical exam grading to return a final 99xxx series code for the encounter.

So what do you need to do?

  • Get comfortable with counting and grading # of diagnoses and management options
  • Get comfortable with grading risk
  • Add the MDM screen to your encounter templates
  • Enter the grading of # of diagnoses and management options and risk to the MDM screen to determine the final medical decision making grade for your 99xxx series visits

As noted earlier, MDM is required for encounter with “new” patients.  It’s not an absolute requirement for those with “established” patients, but neglecting it could lead to coding a lower level than the medical record supports.





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