What Is Medical Decision Making? | Coding | MD&D #26

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Every time you see a patient, you ask yourself questions and make decisions. What is the diagnosis? How serious is the problem? What images or lab tests I need to order? What medication should I prescribe?

All those questions that we build in our minds when we meet a patient, and the plans we set up with the patient and for the patient, are part of a process we call Medical Decision Making, or commonly abbreviated, MDM.

MDM Is More Than the Diagnosis

One of the most common mistakes I see, and one that I used to make, is assuming that a complicated diagnosis automatically means a high-level visit. It doesn't work like that.

Medical decision making considers what you had to evaluate and decide for your encounter with the patient. In the case of outpatient/office visits it uses three elements:

It is very important that you remember these elements. I’m going to expand on each of these below. Don’t worry. But the important thing to remember here is the severity of the disease is not one of the factors.

You can have a relatively mild or benign condition and still qualify for a high-level encounter by using these parameters. The opposite is also true. You can have a severe disease and have a low-level encounter with your patient.

Now, let's look deeper into these three elements:

1. Number and Complexity of the Problems You Addressed

These are the medical problems you are evaluating or managing during the encounter. Not necessarily the problems in the previous medical history. So, simply listing diagnoses in your note does not necessarily increase the complexity of your Medical Decision Making. The problems must be addressed during the encounter, which means you evaluated and established a plan related to this problem.

For example, a patient may have hypertension listed in the medical history. If the hypertension had nothing to do with today's visit and you did not evaluate or manage it, simply having it on the problem list does not make the encounter more complex. You must list the problems that you addressed during the encounter.

We, the clinicians, not the coders, are responsible for determining if the condition is stable, worsening, or improving. Remember that.

2. The Amount and Complexity of the Data You Reviewed for the Encounter

This includes things like interpreting lab results, images, outside records, or other tests. And it may also include getting information and discussing the patient's care with another clinician. But this is another place where a lot of clinicians can get confused. Simply clicking through ten laboratory results does not automatically make the encounter high complexity. The coding system has specific rules about what counts as data. But in simple terms it means: How much information did I need to evaluate to make my decision on how to manage the patient

3. Risk of Patient Management

Notice how this is worded. It doesn’t mean the risk of the disease. It means the risk to the patient that comes from the management plan you made after your evaluation.

For example, prescribing an over-the-counter medication in general has less management risk than a prescription drug. If the patient went home after the visit has a much lower risk than deciding that the patient needs surgery or to be hospitalized. But let me dig even deeper here.

Just having surgery does not automatically classify and encounter as high risk, just because surgeries have inherent risks. The circumstances matter. A procedure in an otherwise healthy patient has a lower Medical Decision Making than the same procedure in someone with major comorbidities or other significant risk factors.

This is why your documentation in the chart should not only reflect how you decided to treat the patient (like surgery for example), but also the clinical circumstances that influenced your decision for surgery, or any other treatment option.

Two Out of Three

And one more thing that is as important, you don’t need to fulfill all three elements to reach a particular level of Medical Decisions Making. You only need to meet two of these three elements. Imagine, for example, that an encounter meets this criteria:

Two elements, problems and risk, are moderate. Then the Medical Decision Making is moderate, even though the data that you analyzed (i.e. labs, images) is minimal.

That concept alone makes the MDM table much easier to understand.

The complexity of the Medical Decision Making

The level of complexity can be then classified as: Straightforward or level 2, Low complexity or level 3, Moderate complexity or level 4 and high complexity: or level 5.We will talk about this in detail in a future article.

Medical Decision Making is basically trying to describe and assess what we do every day: to think. But since the coding system cannot see what was happening in our heads while we addressed the patient’s problems it can only rely on our documentation. That’s what I tell residents and young attendings. If it is not documented, it did not happen.

Understanding Medical Decision Making helps connect the clinical work you performed with the code that represents that work. And just like everything else in coding, the goal is not to code higher. The goal is to code correctly and to document accurately enough to justify that code.

✓ Medical Decision Making is based on what you addressed, reviewed, and decided during the encounter. Not simply on how serious the diagnosis is.
✓ The three Medical Decision Making elements are: the number and complexity of the problems, the data, and risk.
✓ You only need two of these three elements to meet a level for the encounter.

“The goal is not to code higher. It is to code correctly and document clearly enough to support your code selection.”

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