🩺 MDM Tables

🎯 Purpose

A quick‑reference guide for Medical Decision Making (MDM) levels, including Problems, Data, and Risk. Designed for CIC prep, audits, and documentation clarity.

1️⃣ Number & Complexity of Problems Addressed

Level	Problem Types	Examples
Straightforward	1 self‑limited or minor problem	Viral URI, simple rash
Low	2+ self‑limited problems OR 1 stable chronic illness OR 1 acute, uncomplicated illness	Controlled HTN, simple UTI
Moderate	1+ chronic illness with exacerbation OR 2+ stable chronic illnesses OR undiagnosed new problem with uncertain prognosis OR acute illness with systemic symptoms	New abdominal pain, COPD flare
High	1+ chronic illness with severe exacerbation OR acute or chronic illness posing threat to life or function	MI, stroke symptoms, sepsis

2️⃣ Amount & Complexity of Data Reviewed

Data Categories

Category 1: Tests, documents, orders
- Review of labs, imaging, notes
- Ordering tests
- Independent historian
Category 2: Independent interpretation
- Provider interprets test (not separately billed)
Category 3: Discussion
- Discussion of management/test with external physician or qualified health professional

Data by Level

Level	Requirements
Straightforward	Minimal or none
Low	Limited data (e.g., 1-2 tests ordered/reviewed)
Moderate	1 of: • Category 1 (≥3 items) OR • Category 2 OR • Category 3
High	2 of: • Category 1 (≥3 items) AND • Category 2 AND/OR Category 3

3️⃣ Risk of Complications & Morbidity

Level	Risk Examples
Straightforward	OTC meds, minor procedures
Low	Prescription drug management, minor surgery with no risk factors
Moderate	Decision for minor surgery with risk factors, escalation of care, chronic illness with exacerbation
High	Decision for major surgery, hospitalization, DNR decisions, severe exacerbations

🧮 Putting It All Together: MDM Level Requirements

MDM level is based on 2 of the 3 elements:

Problems
Data
Risk

MDM Level	Problems	Data	Risk
Straightforward	Minimal	Minimal	Minimal
Low	Low	Limited	Low
Moderate	Moderate	Moderate	Moderate
High	High	Extensive	High

🧠 Quick Audit Notes

Document why a problem is worsening or severe
Link tests to the problem being evaluated
Clarify risk factors when prescribing meds
Note shared decision‑making when applicable
Capture external discussions clearly

🔗 Cross‑Links