Medical Decision Making 101
In this article, we are going to briefly discuss the basics of MDM (Medical Decision Making).
Presenting Problem(s)
Consider using the MEAT method for determining your level for presenting problems.
Problem Addressed – A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.
M=Monitoring
E=Evaluating
A=Assessment
T=Treatment
Data
Category 1: Tests, documents, or independent historian(s) (Each unique test = CPT code)
Category 2: Independent interpretation of tests (that you aren’t billing for)
Category 3: Discussion of management or test interpretation (with external providers)
Risk
Low: Low risk of morbidity from additional diagnostic testing or treatment
Moderate: Moderate risk of morbidity from additional diagnostic testing or treatment
Examples only:
• Prescription drug management
• Decision regarding minor surgery with identified patient or
procedure risk factors
• Decision regarding elective major surgery without identified
patient or procedure risk factors
• Diagnosis or treatment significantly limited by social determinants
of health
High: High risk of morbidity from additional diagnostic testing or treatment
Examples only:
• Drug therapy requiring intensive monitoring for toxicity
• Decision regarding elective major surgery with identified patient or
procedure risk factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of poor
prognosis
In order to select your MDM level (Straightforward, Low, Moderate, or High), you must meet or exceed at least (2) of the (3) components (Diagnosis, Data, Risk) required. (Cheat Sheet here)
For more information regarding the 2023 Inpatient E/M Changes, please see our dedicated page here.
Update: AMA – Clinical Vignettes Package here. 09/12/2023
If you would like additional training, please contact Jay.McVean@uth.tmc.edu or Caroline.Wolbrecht@uth.tmc.edu to schedule for your department.