{"id":9953,"date":"2019-10-21T14:06:51","date_gmt":"2019-10-21T08:36:51","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=9953"},"modified":"2025-08-11T11:07:49","modified_gmt":"2025-08-11T11:07:49","slug":"quantifying-your-medical-decision-making","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/quantifying-your-medical-decision-making\/","title":{"rendered":"Quantifying Your Medical Decision-Making"},"content":{"rendered":"<h2>Quantifying Cognitive Labor<\/h2>\n<p style=\"text-align: justify;\">This is the most important of the three key components because the Medical Decision-Making (MDM) reflects the intensity of the cognitive labor performed by the physician. There are four levels of MDM of incrementally increasing complexity Straightforward; Low Complexity; Moderate Complexity; and High Complexity.<\/p>\n<h3 style=\"text-align: left;\">Physicians must stratify the MDM into one of the above levels of complexity based on:<\/h3>\n<table width=\"0\">\n<tbody>\n<tr>\n<td width=\"113\">\n<h4>Number of diagnoses or management options<\/h4>\n<\/td>\n<td width=\"103\">\n<h4>The amount and\/or complexity of data to be reviewed<\/h4>\n<\/td>\n<td width=\"109\">\n<h4>Risk of complications and\/or morbidity or mortality<\/h4>\n<\/td>\n<td width=\"144\">\n<h4>Level of Complexity of Medical Decision-Making<\/h4>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"113\">Minimal<\/td>\n<td width=\"103\">Minimal or None<\/td>\n<td width=\"109\">Minimal<\/td>\n<td width=\"144\">Straightforward<\/td>\n<\/tr>\n<tr>\n<td width=\"113\">Limited<\/td>\n<td width=\"103\">Limited<\/td>\n<td width=\"109\">Low<\/td>\n<td width=\"144\">Low Complexity<\/td>\n<\/tr>\n<tr>\n<td width=\"113\">Multiple<\/td>\n<td width=\"103\">Moderate<\/td>\n<td width=\"109\">Moderate<\/td>\n<td width=\"144\">Moderate Complexity<\/td>\n<\/tr>\n<tr>\n<td width=\"113\">Extensive<\/td>\n<td width=\"103\">Extensive<\/td>\n<td width=\"109\">High<\/td>\n<td width=\"144\">High Complexity<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">When referring to the table, the level of risk is determined by examining three separate dimensions of the encounter:<\/p>\n<ul>\n<li style=\"text-align: left;\">Presenting Problems<\/li>\n<li style=\"text-align: left;\">Diagnostic Procedures<\/li>\n<li style=\"text-align: left;\">Management Options Selected<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><strong>Tip:<\/strong> The E\/M guidelines explicitly state that the highest level of risk present in any one of the above categories determines the overall risk of the encounter. <a href=\"https:\/\/www.medicalbillersandcoders.com\/physician-group.aspx\">Physicians<\/a> often underestimate the level of risk as defined by the E\/M guidelines.<\/p>\n<h2 style=\"text-align: left;\">Decision-Making Point System<\/h2>\n<p style=\"text-align: justify;\">A casual review of the official rules for interpreting the key component of Medical Decision-Making shows that the criteria for quantifying physician cognitive labor are quite ambiguous. <a href=\"https:\/\/www.medicare.gov\/index\">Medicare<\/a> discovered that auditors were having a hard time nailing down the level of Medical Decision-Making during the medical review process.<\/p>\n<p style=\"text-align: justify;\">In response to this problem, a more objective Medical Decision-Making Point System was developed by CMS. Although not part of the official E\/M guidelines, this MDM Point System was distributed to all Medicare carriers to be used on a &#8220;voluntary&#8221; basis.\u00a0 In point of fact, this is the way your Medical Decision-Making will be graded in the event of an audit.<\/p>\n<p style=\"text-align: justify;\">This approach uses a matrix of weighted points to answer most of the questions left open by the official E\/M guidelines regarding the MDM.\u00a0 Instead of vague words like \u201cextensive\u201d, the MDM Point System uses a numeric scale to describe the number and nature of the diagnoses being addressed.\u00a0 These issues are quantified using \u201cProblem Points\u201d.<\/p>\n<p style=\"text-align: justify;\">Similarly, the extent of the data reviewed is quantified by using \u201cData Points\u201d which reflect the volume and complexity of the information processed by the physician.\u00a0 Risk is determined by referring to the identical table of risk used by the official E\/M guidelines.<\/p>\n<h2 style=\"text-align: left;\">Problem Points<\/h2>\n<p style=\"text-align: justify;\">The \u201cnature and number of clinical problems\u201d are quantified into Problem Points by referring to the following table:<\/p>\n<table width=\"0\">\n<tbody>\n<tr>\n<td width=\"275\">\n<h3>Problems<\/h3>\n<\/td>\n<td width=\"64\">\n<h3>Points<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"275\">Self-limited or minor (maximum of 2)<\/td>\n<td width=\"64\">1<\/td>\n<\/tr>\n<tr>\n<td width=\"275\">Established problem, stable or improving<\/td>\n<td width=\"64\">1<\/td>\n<\/tr>\n<tr>\n<td width=\"275\">Established problem, worsening<\/td>\n<td width=\"64\">2<\/td>\n<\/tr>\n<tr>\n<td width=\"275\">New problem, with no additional work-up planned (maximum of 1)<\/td>\n<td width=\"64\">3<\/td>\n<\/tr>\n<tr>\n<td width=\"275\">New problem, with additional workup planned<\/td>\n<td width=\"64\">4<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">The above table is fairly self-explanatory.\u00a0 An example of a \u201cself-limited or minor\u201d problem may be a common cold or an insect bite.\u00a0 An \u201cestablished problem\u201d refers to a diagnosis, which is already known to the examiner, such as hypertension, osteoarthritis or diabetes.<\/p>\n<p style=\"text-align: justify;\">An example of a \u201cnew problem with no additional workup planned\u201d may be a new diagnosis of essential hypertension.\u00a0 Examples of \u201cnew problem, with additional workup planned\u201d may include any new clinical issue which requires further investigation such as chest pain, proteinuria, anemia, shortness of breath, etc.<\/p>\n<p style=\"text-align: justify;\"><strong>Tip:<\/strong> Problems that are not being addressed specifically by the physician during the encounter may still be counted if they significantly increase the complexity of the cognitive labor required.\u00a0 For example, consider a patient with diabetes who is being evaluated by a vascular surgeon for a lower extremity revascularization procedure.<\/p>\n<p style=\"text-align: justify;\">It would be appropriate for the surgeon to include diabetes as an \u201cestablished problem, stable\u201d when calculating the problem points.\u00a0 This is because the comorbidity of diabetes does significantly influence the risk of the procedure and the complexity of post-operative management.<\/p>\n<p style=\"text-align: justify;\"><strong>Tip:<\/strong> Problems are defined relative to the examiner, not the patient.\u00a0 Even if the problem was previously known to other physicians or to the patient, it is still considered new to you if you are seeing the patient for the first time. This situation arises often in the case on consultations.<\/p>\n<h2 style=\"text-align: left;\">Data Points<\/h2>\n<p style=\"text-align: left;\">The \u201camount and complexity of the data reviewed\u201d are quantified by referring to the following table:<\/p>\n<table width=\"0\">\n<tbody>\n<tr>\n<td width=\"292\">\n<h3>Data Reviewed<\/h3>\n<\/td>\n<td width=\"87\">\n<h3>Points<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"292\">Review or order clinical lab tests<\/td>\n<td width=\"87\">1<\/td>\n<\/tr>\n<tr>\n<td width=\"292\">Review or order radiology test (except heart catheterization or echo)<\/td>\n<td width=\"87\">1<\/td>\n<\/tr>\n<tr>\n<td width=\"292\">Review or order medicine test (PFTs, EKG, cardiac echo or catheterization)<\/td>\n<td width=\"87\">1<\/td>\n<\/tr>\n<tr>\n<td width=\"292\">Discuss test with performing physician<\/td>\n<td width=\"87\">1<\/td>\n<\/tr>\n<tr>\n<td width=\"292\">Independent review of image, tracing, or specimen<\/td>\n<td width=\"87\">2<\/td>\n<\/tr>\n<tr>\n<td width=\"292\">Decision to obtain old records<\/td>\n<td width=\"87\">1<\/td>\n<\/tr>\n<tr>\n<td width=\"292\">Review and summation of old records<\/td>\n<td width=\"87\">2<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">The physician should be aware that no \u201cdouble-dipping\u201d is allowed.\u00a0 For example, if you review lab results and order labs during the same visit, you only get one point (not one point for ordering and one point for reviewing).\u00a0 This same rule applies to image studies or other medical tests such as EKGs or PFTs.<\/p>\n<p style=\"text-align: justify;\">Commonly overlooked points are those garnered for obtaining or reviewing old records.\u00a0 If you do review old records, you must summarize your findings in the chart.\u00a0 It is not acceptable to just say, \u201cOld records were reviewed.\u201d<\/p>\n<p style=\"text-align: justify;\"><strong>Tip:<\/strong> Notice that points can accumulate quickly if you personally review an image, tracing or specimen.\u00a0 You can still claim these points, even if the image, tracing or specimen has been reviewed by another physician (as when a radiologist provides an official interpretation for an X-ray).\u00a0 However, you must include your own interpretation in the chart in order to claim these points.<\/p>\n<p style=\"text-align: justify;\">After calculating the Problem Points and the Data Points and stratifying the level of risk, the overall complexity of MDM is determined by referring to the yet another table:<\/p>\n<h2 style=\"text-align: left;\">MDM Points Table<\/h2>\n<p style=\"text-align: left;\">(Two out of three must be present to qualify for a given level of MDM)<\/p>\n<table width=\"0\">\n<tbody>\n<tr>\n<td width=\"129\">\n<h3>Overall MDM<\/h3>\n<\/td>\n<td width=\"79\">\n<h3>Problem Points<\/h3>\n<\/td>\n<td width=\"76\">\n<h3>Data Points<\/h3>\n<\/td>\n<td width=\"80\">\n<h3>Risk<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"129\">Straightforward Complexity<\/td>\n<td width=\"79\">1<\/td>\n<td width=\"76\">1<\/td>\n<td width=\"80\">Minimal<\/td>\n<\/tr>\n<tr>\n<td width=\"129\">Low complexity<\/td>\n<td width=\"79\">2<\/td>\n<td width=\"76\">2<\/td>\n<td width=\"80\">Low<\/td>\n<\/tr>\n<tr>\n<td width=\"129\">Moderate Complexity<\/td>\n<td width=\"79\">3<\/td>\n<td width=\"76\">3<\/td>\n<td width=\"80\">Moderate<\/td>\n<\/tr>\n<tr>\n<td width=\"129\">High Complexity<\/td>\n<td width=\"79\">4<\/td>\n<td width=\"76\">4<\/td>\n<td width=\"80\">High<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h4>Example:<\/h4>\n<p>Suppose you see a patient in the office with stable diabetes and sub-optimally controlled hypertension.\u00a0 After checking routine labs, you decide to increase the patient\u2019s lisinopril from 10 to 20 mg po qd.\u00a0 If you calculate the individual points and assign a level of risk, the MDM table for this encounter would look like this:<\/p>\n<table width=\"0\">\n<tbody>\n<tr>\n<td width=\"121\">\n<h5>Overall MDM<\/h5>\n<\/td>\n<td width=\"67\">\n<h5>Problem Points<\/h5>\n<\/td>\n<td width=\"63\">\n<h5>Data Points<\/h5>\n<\/td>\n<td width=\"79\">\n<h5>Risk<\/h5>\n<\/td>\n<\/tr>\n<tr>\n<td width=\"121\">Straightforward Complexity<\/td>\n<td width=\"67\">1<\/td>\n<td width=\"63\">1<\/td>\n<td width=\"79\">Minimal<\/td>\n<\/tr>\n<tr>\n<td width=\"121\">Low complexity<\/td>\n<td width=\"67\">2<\/td>\n<td width=\"63\">2<\/td>\n<td width=\"79\">Low<\/td>\n<\/tr>\n<tr>\n<td width=\"121\">Moderate Complexity<\/td>\n<td width=\"67\">3<\/td>\n<td width=\"63\">3<\/td>\n<td width=\"79\">Moderate<\/td>\n<\/tr>\n<tr>\n<td width=\"121\">High Complexity<\/td>\n<td width=\"67\">4<\/td>\n<td width=\"63\">4<\/td>\n<td width=\"79\">High<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Since it only takes two out of three elements to qualify for any level of MDM, it is clear that this encounter qualifies for \u201cModerate Complexity\u201d medical decision-making because of:<\/p>\n<ul>\n<li style=\"text-align: left;\">Three Problem Points (one point for diabetes&#8211; established problem, two points for hypertension\u2014established problem, worsening)<\/li>\n<li style=\"text-align: left;\">One Data Point for reviewing labs<\/li>\n<li style=\"text-align: left;\">Moderate Risk due to the management option selected of \u201cprescription drug management\u201d<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><strong>Tip:<\/strong> The MDM point system provides a repeatable and objective way for the physician to measure the cognitive labor required to address the clinical issues of any encounter. Many physicians systematically underestimate the value of their medical decision-making.<\/p>\n<p style=\"text-align: justify;\">This occurs because there is a tendency to equate \u201croutine\u201d thought processes with \u201cstraightforward\u201d medical decision-making which is simply not true. Utilizing the objective MDM point system can help you avoid this self-deprecating pattern of behavior.<\/p>\n<h2>FAQs<\/h2>\n\n\n<div class=\"schema-faq wp-block-yoast-faq-block\"><div class=\"schema-faq-section\" id=\"faq-question-1754910405207\"><strong class=\"schema-faq-question\">1. What is Medical Decision-Making (MDM)?<\/strong> <p class=\"schema-faq-answer\">MDM reflects the complexity of cognitive labor performed by a physician during patient encounters, categorized into four levels: Straightforward, Low Complexity, Moderate Complexity, and High Complexity.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1754910419685\"><strong class=\"schema-faq-question\">2. How is the level of MDM determined?<\/strong> <p class=\"schema-faq-answer\">MDM is stratified based on three factors: the number of diagnoses, the complexity of data reviewed, and the risk of complications or mortality.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1754910430601\"><strong class=\"schema-faq-question\">3. What are the Problem Points in the MDM Point System?<\/strong> <p class=\"schema-faq-answer\">Problem Points quantify the nature and number of clinical problems addressed, ranging from 1 point for minor issues to 4 points for new problems requiring additional workup.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1754910442404\"><strong class=\"schema-faq-question\">4. How are Data Points calculated?<\/strong> <p class=\"schema-faq-answer\">Data Points reflect the complexity of data reviewed, with points assigned for ordering or reviewing tests, discussing results, and reviewing old records, among other factors.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1754910452994\"><strong class=\"schema-faq-question\">5. Why is the MDM Point System important?<\/strong> <p class=\"schema-faq-answer\">The MDM Point System provides an objective method to quantify cognitive labor, helping physicians accurately reflect the complexity of their decision-making during audits and improving reimbursement potential.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"<p>Quantifying Cognitive Labor This is the most important of the three key components because the Medical Decision-Making (MDM) reflects the intensity of the cognitive labor performed by the physician. There are four levels of MDM of incrementally increasing complexity Straightforward; Low Complexity; Moderate Complexity; and High Complexity. Physicians must stratify the MDM into one of [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":9954,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[65],"tags":[1086,1992,1993,1994,1995,1996,1997,162,64,1998,1999,192,150,815,816,2000,2001,2002],"class_list":["post-9953","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-practice-management","tag-american-healthcare-billing-services","tag-coding-basics-medical-decision-making-is-the-key","tag-decision-making-point-system","tag-defining-and-measuring-diagnostic-uncertainty-in-medicine","tag-measuring-shared-decision-making","tag-measuring-shared-decision-making-and-collaborative-goal","tag-measuring-the-immeasurable","tag-medical-billing-and-coding-services","tag-medical-billing-practices","tag-medical-decision-making-e-m-coding","tag-medical-decision-making-for-e-m-services","tag-medicare-medicaid-services","tag-medicare-claims","tag-outsourced-medical-billing-company","tag-outsourced-medical-billing-services","tag-quantifying-uncertainty-in-medical-decisions","tag-quantifying-your-medical-decision-making","tag-the-need-for-uncertainty-quantification-in-machine"],"yoast_head":"<!-- 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