How do you calculate medical decision-making complexity?

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Medical Decision Making (MDM) complexity is calculated based on three key elements:

1. Number and complexity of problems addressed

2. Amount and/or complexity of data to be reviewed and analyzed

3. Risk of complications and/or morbidity or mortality of patient management

Each element is evaluated individually, and the overall MDM level is determined by combining them according to the 2021 E/M guidelines.

1. Problems Addressed

• Count the number of problems/diagnoses managed in the encounter.

• Consider problem severity and status (new, stable, worsening).

• Examples:

  • Minimal: One self-limited problem

  • Low: Two or more stable chronic problems

  • Moderate: Multiple chronic problems or an acute complicated illness

  • High: Severe or life-threatening problems

2. Data to Be Reviewed and Analyzed

Includes:

• Tests ordered or reviewed (labs, imaging, EKGs)

• Records or notes from others

• Independent interpretation of tests

• Discussion with other healthcare professionals

• The quantity and complexity of data reviewed influences this element.

3. Risk of Complications or Morbidity/Mortality

• Based on the risk associated with the management decisions, such as:

  • Prescribing new medication or surgery

  • Diagnostic procedures with risk

  • Patient’s comorbidities and condition severity

You must meet or exceed the required elements per level, often needing at least 2 of 3 categories at the same level.

Accurate MDM coding ensures appropriate billing and reflects the clinical complexity of care.

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