The Documentation Guidelines did not include a point system for medical decision making. The Guidelines describe three components of medical decision making.
A picture is worth a thousand words: there is an audit sheet in the resources section of this article: print it out while reading this article.
The first is the number of diagnoses treated. The guidelines assume that new problems to the examiner that need a work up are more complex than new problems that do not require a work up. Also, that existing problems that are worsening or not responding to treatment are more complex than those that are better or stable or responding well to treatment.
The second component of MDM is the amount of data to be reviewed. This includes ordering and/or reviewing diagnostic tests, reviewing and summarizing old records, obtaining history from someone other than the patient, discussion with a testing physician, and personally reviewing a tracing or image, (as opposed to reviewing the report of that test.)
The third component of MDM is the risk of complications, morbidity and/or mortality, what is commonly known as the table of risk. The table of risk is divided into the risk of the presenting problem, the risk related to the diagnostic testing and the risk related to the treatment of the problem. Any one item from the table of risk, in any of the three categories, determines the risk.
There is a table in the Guidelines that shows us what level of each of the components is straightforward, low, moderate and high complexity.
The Marshfield Clinic developed a point system to help operationalize this section of the Guidelines, which are most open to interpretation. These points are found on most audit sheets. (And there is one attached to this article in the resource section.)
The Marshfield Clinic assigned points this way:
For the first component of MDM, the number of diagnoses: minor or straightforward problems = 1 point, maximum of 2 allowed; stable problems =1 point; worsening problems =2 points; new problem to the examiner, no workup =3 points, one allowed; new problem to examiner with workup= 4 points.
For data: reviewing or ordering one or many lab tests =1 point; reviewing or ordering one or many x-rays =1 point; reviewing or ordering one or many medical tests =1 point; discussion with testing physician= 1 point; decision to obtain old records = 1 point; reviewing and summarizing old records = 1 or 2 points, depending on carrier; independently reviewing a tracing/image 1 or 2 points, depending on the carrier.
For the table of risk, 1 point is given for a presenting problem, diagnostic test or treatment that is minimal, 2 for low, 3 for moderate and 4 for high. Look at the table of risk to see examples.
Two of the three complexity elements are required to meet the level of MDM, which are straightforward, low, moderate and high.
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