Medical Coding and the Levels of Medical Decision-Making Table

by  Find-A-Code™
Jan 29th, 2024

We are firm believers in complete training and certification for medical coders and billers. There is a lot to know in order to be a competent biller or coder. You need to know more than just how to look up medical billing codes online. For example, you need to know and understand the Levels of Medical Decision Making (MDM) table.

The MDM table looks simple enough at first glance. But dig a little deeper and you discover that it is a complex tool for figuring out how to code individual medical encounters through appropriate application of the "Levels of Medical Decision Making". Without a thorough understanding of the information in the table, it is extremely easy to make medical coding mistakes.

At the root of the MDM table is the concept of determining the amount of medical decision making that occurs during a particular encounter between clinician and patient. Some encounters are pretty straightforward. They don't require a whole lot of decision making. Other encounters are more complex. The level of "Complexity" needs to be appropriately determined in order to code correctly (select the proper level of MDM).

Four Levels of Medical Decision Making

The MDM table offers two types of information to deal with, beginning with the level of complexity for a particular encounter. There are four levels as follows:

1. Straightforward – Straightforward encounters represent those with minimal complexity. The related data is limited, there is a low risk of complications, and diagnoses are few. These tend to be the simplest of all medical encounters.
2. Low Level – Low level encounters generate a little more data and diagnosis. They also come with a low risk of complications.
3. Moderate Level – Moderate level encounters generate a moderate volume of data. There is also the potential for multiple diagnoses along with a higher risk (moderate level) of complications.
4. High Level – High level encounters are the most complex of all. They generate large amounts of data and are typically associated with complex diagnoses. The risk of complications is also relatively high.

Although each of the four levels is distinct and different, they all have one thing in common: ambiguity. Although there are some requirements listed (e.g., comination of bulleted items), in many cases there are no black-and-white standards for applying each level. One coder's definition of 'moderate data volume' might be construed by another coder or reviewer as a low level of data. Therefore, there is room for interpretation in this regard; however, being careful to apply the rules that are available can help to minimize this confusion.

Three Elements of Medical Decision Making to Consider

Medical coders and billers need to thoroughly understand the three elements of MDM. How they assess these three elements helps them select the most appropriate level of medical decision making that best describes the medical encounter they are coding. Here are the three elements:

1. The number and complexity of medical issues dealt with during the encounter
2. The volume (amount) and/or complexity of the data utilized during the encounter
3. The risk of complications, morbidity, or mortality associated with treatment options and managing the patient's health

Once again, there is plenty of room for interpretation here. Needless to say that utilizing the MDM table isn't a terribly scientific exercise. It is one that requires experience, medical knowledge, and at least a working knowledge of how a particular clinician operates as well as knowing payer guidelines. Using the table correctly also requires a lot of practice.

Experience Is a Coder's Best Friend

If nothing else, this brief look at the MDM table illustrates the reality that experience is a medical coder's best friend. Likewise for medical billing. Coders and billers can learn a lot in the classroom. They can glean tons of information from online sources and printed materials. But at the end of the day, nothing substitutes for hands-on experience. If you are looking to become a medical coder or biller, be prepared for the fact that the learning never stops.