What is the difference between “Moderate” and “High complexity” medical decision making under the Centers for Medicare and Medicaid Services (CMS) rule?

The level of medical decision making (“Straightforward/Low complexity”, “Moderate complexity”, “High complexity”) or MDM should reflect the intensity of the cognitive labor performed by the clinician.

The MDM level is determined by 3 important factors:

  • The nature and number of clinical problems
  • The amount and complexity of data reviewed by the clinician
  • The risk of morbidity and mortality to the patient

As for the nature of clinical problems, in contrast to stable problems (1 point), the following receive higher points:

  • Established problems that are worsening (2 points)
  • New problems for which no further workup is planned (3 points)
  • New problems for which additional workup is planned (4 points)

As for the amount and complexity of data reviewed by the clinician, the following receive higher points (2 points each)

  •  Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider
  • Independent visualization of image, tracing or specimen itself (not simply review of report)

More routine activities such as simply reviewing or ordering lab, radiology, or other tests, discussing tests results with performing physician, or obtaining old records and/or history from someone other than patient receive only 1 point each.

The 3rd element of MDM scoring system is based on the risk of complications and/or morbidity or mortality determined by the severity of the presenting problem(s), complexity of the diagnostic procedure(s) ordered, and management options selected.

Patients may be considered “High risk” of complications and/or morbidity or mortality when any of following is documented: 

A. Presenting problem(s)

  • ≥1 chronic illnesses with severe exacerbation, progression, or side effects of treatment
  • Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure
  • An abrupt change in neurologic status, eg, seizure, TIA, weakness or sensory loss

B. Diagnostic procedure(s) ordered

  •  Cardiovascular imaging studies with contrast with identified risk factors
  • Cardiac electrophysiologic tests
  • Diagnostic endoscopies with identified risk factors
  • Discographies

C. Management options selected

  •  Elective major surgery (open, percutaneous or endoscopic with identified risk factors)
  • Emergency major surgery (open, percutaneous or endoscopic)
  • Parenteral controlled substances
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision not to resuscitate or to de-escalate care because of poor prognosis

Less severe conditions such as pyelonephritis, pneumonitis, colitis, or head injury with brief loss of consciousness, and less complicated procedures such as diagnostic endoscopies and elective major surgery with no identified risk factor are considered “Moderate risk”.

 To qualify for “High complexity” care, at least 2 of the following must be present:

  • High (≥4 points) score in number of diagnoses or treatment option
  • High ((≥4 points) score in the amount and complexity of data gathered
  • High risk of complications and/or morbidity or mortality

Otherwise, your patient encounter qualifies for “Moderate” or lower complexity  care.

For further details on how to determine the MDM level on your individual patient go to:

https://www.ngsmedicare.com/ngs/wcm/connect/3632a905-b697-4266-8fc0-2aa2a84fedb2/1074_0514_EM_Documentation_Training_Tool_508.pdf?MOD=AJPERES

Contributed by Jodie Medeiros, CPC, COC, ICDCT-CM, Billing Specialist, Mass General Hospital, Boston, MA

 

What is the difference between “Moderate” and “High complexity” medical decision making under the Centers for Medicare and Medicaid Services (CMS) rule?