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Thread: Medical Decision Making

  1. #1
    Join Date
    Apr 2007

    Default Medical Decision Making

    AAPC: Back to School
    When determining the level of medical decision making by the 1997 guidelines, is it two out of three (# dx or management options, amount and complexity of data, highest risk), or second circle from the left. The problem is if a patient has 3 dx points, 1 data point, and risk is moderate, is it still a 99214 because there are only two data points? Thanks

    Heather Winters, CPC, CFPC

  2. #2
    Join Date
    Apr 2007


    For the total for Medical Decision Making, it is 2 out of 3 for the number of diagnosis and management options, amount/complexity of data and table of risk. So as in your example, if you have 3 dx points, 1 data point and moderate risk, you would have moderate complexity medical decision making. Which would be the MDM for a 99214 but you would have to go back to your table with your history and exam, put in your moderate MDM and see how they line up to meet a level of E/M. If both your history and exam were problem focused, even though your MDM was moderate, you aren't going to have a 99214. It's 2 out of 3 here (for an established patient) that determines your level of E/M.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I
    AHIMA Approved ICD-10-CM/PCS Trainer
    AAPC National ICD-10-CM Trainer

  3. #3
    Join Date
    Apr 2007
    Duluth, Minnesota


    Nicely said! - I agree, and you stated it very clearly. Just to reinderate what bpct6501 said;
    Though the "moderate" MDM falls in the 99214/99204 line (established pt/new patient) - that alone does not make a level 4 office visit. All three components - HISTORY-EXAM-MDM are taken into consideration when determining the level of E/M. (2 of 3 for est and 3 of 3 for new/consult)
    Donna, CPC, CPC-H

  4. #4
    Join Date
    Apr 2007

    Default Yes

    Yes--the past two responses are correct. The MDM would be Moderate (99214) but you'll have to look at the history and exam to get the final code assignment.
    It takes a little time to get the hang of auditing, but once you get the basics down you'll find it gets easier. Hope this helps!
    Carrie, BS, CPC

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