AAPC - Back to school
Results 1 to 7 of 7

Thread: Mdm

  1. #1

    Default Mdm

    AAPC: Back to School
    I did a chart audit for an established patient yesterday where the components of the MDM were all different:
    No of DX or TX options-Moderate
    Amt/complexity of data reviewed/ordered-Low
    Risk of Complications, Morbidity, Mortality-Minimal

    Should I have chosen the lower, middle or higher value?

  2. #2

    Default 2 of the three or in the middle...

    Middle, from what I have been taught. It has to be 2 stacked up or the one in the middle.

    I hope this helps!


  3. #3

    Default Use the highest level

    You want to use the highest level circled. If you take a look at the Risk of Complications and/or Morbidity or Mortality table, it specifically says "circle the most appropriate factor(s) in each category. The overall measure of risk is the highest level circled."

    Megan, CPC

  4. #4
    Join Date
    Apr 2007
    Bridgeport, CT

    Default MDM Criteria

    According to the 1995 E/M documentation guidelines:

    To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.

    So, when you have a bullet in each of the levels, you drop the lowest and go with the midpoint.


  5. #5
    Join Date
    Apr 2007
    Milwaukee WI

    Default Two of the three meet or exceed

    Two of the three elements must meet or exceed. You drop the lowest, and then go with the lowest of the ones left.

    It would be helpful if you actually told us the number of data points and problem points.

    But ....
    Problem points: you state "moderate" so I'll assume you mean 3 points
    Data points: you state "low" which on my audit tool equates to 1 point
    Risk: you state Minimal

    So you have two at Minimal or Low and 1 at Moderate.
    If you drop the lowest, you still only have 1 at Low and 1 at Moderate so your level of MDM is STRAIGHTFORWARD.

    F Tessa Bartels, CPC, CEMC

  6. #6


    I agree with Scott, I have been taught that if you have...

    Number of diagnosis and treatment options, let say (3) for new problem to examiner to additional workup planned

    Risk of complications, let's say, ove the counter drugs were recommended = low

    Amount and/or complexity of data to be reviewed= 1 (clinical lab tests)

    Two of them need to meet or go with the one in the middle...

    Is this not correct????


  7. #7

    Default Addendum

    I do agree with the above. For some reason, I thought you were just talking about the table of risk. You should go for the lowest or the middle in order to ensure "at least two elements must meet or exceed level requirements".

Similar Threads

  1. Mdm?
    By tcoder5 in forum E/M
    Replies: 2
    Last Post: 09-18-2013, 09:46 AM
  2. Mdm
    By torih@nwurology.com in forum E/M
    Replies: 2
    Last Post: 06-13-2013, 10:39 AM
  3. MDM needs to be 1 of the 2 ?
    By terio in forum E/M
    Replies: 3
    Last Post: 02-20-2012, 09:40 AM
  4. MDM Help please
    By gmitch02 in forum E/M
    Replies: 2
    Last Post: 10-27-2010, 09:59 AM
  5. Mdm
    By LTibbetts in forum E/M
    Replies: 1
    Last Post: 10-05-2010, 01:08 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.