2024 - E/M Calculator by MDM


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History  
Examination  
Medical Decision Making (MDM)
Number and Complexity of Problems Addressed
level Problem(s) Status (select all that apply)
Minimal 1 self-limited/minor
Low 2+ self-limited/minor
1 stable chronic
1 acute, uncomplicated injury/illness
1 stable, acute illness
1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care
Moderate 1+ chronic illness exacerbated, progressing, or side effects of treatment
2+ stable chronic illnesses
1 undiagnosed/new problem with uncertain prognosis
1 acute illness with systemic symptoms
1 acute complicated illness/injury
High 1+ chronic illnesses with severe exacerbation, progression, or side effects of treatment
1 acute or chronic illness/injury posing threat to life or bodily function
Result:  N/A
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Amount and/or Complexity of Data
reviewed data
None or minimal
Review of prior external note(s) from each unique* source
Review of result(s) from each unique* test
Ordering of each unique* test
Assessment requiring an independent historian(s)
Independent interpretation of a test performed by another physician/QHP (not separately reported)
Discussion of management or test interpretation with external physician or QHP/appropriate source (not seperately reported)
Result:  Minimal
*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.
(see CPT code set definition of singular vs multiple test)


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Risk of Patient Management (Complications, and/or Morbidity, or Mortality
level Examples
Minimal Risk

Minimal risk of morbidity from additional diagnostic testing or treatment

Low Risk

Low risk of morbidity from additional diagnostic testing or treatment

Moderate Risk Examples only:
  • Prescription drug management
  • Decision for minor surgery with identified patient or procedure risk factors
  • Decision for elective major surgery without identified patient or procedure risk factors
  • Diagnosis or treatment significantly limited by social determinants of health
High Risk Examples only:
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision regarding elective major surgery with identified patient or procedure risk factors
  • Decision for emergency major surgery
  • Decision for hospitalization or escalation of hospital-level care
  • Decision for Do Not Resuscitate (DNR) or de-escalation of care for poor prognosis
  • Parenteral controlled substances
Result:  N/A
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MDM Result
mdm complexity is based on the 2nd lowest of the components
number/complexity of problems addressed minimal limited moderate high
amount & complexity of data minimal or none limited moderate extensive
risk minimal low moderate high
mdm complexity straightforward low moderate high
Level of Service
 
Level of Service is based on the mdm complexity
mdm complexity straightforward low moderate high
Level 99202 99203 99204 99205


MDM Calculated Level of Service:  N/A 
A medically appropriate history and/or examination MUST be documented for each E/M encounter

E/M Calculator is Developed by Pure RCM

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