Tables breaking down the 3 elements of determining the level for medical decision making.
Official guidance: https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx
Unofficial guidance: this table I made
Updated 10/5/2021 to correct the historian piece. I thought you could only use “assessment requiring an independent historian” (aka almost everything in pediatrics) as a separate category in low MDM, but it’s actually a piece you can use to achieve moderate amount and/or complexity of data to be reviewed and analyzed by achieving any combination of 3 orders placed, results reviewed, notes/documents reviewed, OR use of independent historian.
For example, this week I saw a kiddo who needed two different cultures sent, and his mom served as historian.
In the MDM-Data table, the visit meets moderate because of two different lab orders + historian.
In the MDM-Risk table, the visit meets moderate because of prescriptions written.
2 of 3 tables were moderate complexity, therefore the visit meets level 4 requirements.
In the official document this is described as:
Moderate
(Must meet the requirements of at least 1 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
• Any combination of 3 from the following:
• Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;
• Ordering of each unique test*;
• Assessment requiring an independent historian(s)
or
Category 2: Independent interpretation of tests
• Independent interpretation of a test performed by another physician/other qualified health care professional (not
separately reported);
or
Category 3: Discussion of management or test interpretation
• Discussion of management or test interpretation with external physician/other qualified health care
professional\appropriate source (not separately reported)
COMMENTS