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STRAIGHTFORWARD
MEDICAL DECISION-MAKING
 

 
Straightforward Medical Decision-Making is the lowest level of Medical Decision-Making.  It is impossible not to qualify for it.  This level complexity is required for very, very routine encounters such as a level 2 office follow-up (99212) or a level 1 new office patient (99201).  This level of care is so feeble, you have to wonder why the patient came to the doctor in the first place.  The degree of risk corresponds to a patient with an insect bite.

Straightforward Medical Decision-Making

(Only two out of three elements are required)
Overall MDM Problem Points Data Points Risk
Straightforward Complexity 1 1 Minimal
Low complexity 2 2 Low
Moderate Complexity 3 3 Moderate
High Complexity 4 4 High
Requires two out of three of the following : Clinical Example

A 41 year old female referred from an urgent care clinic for left arm pain.  She was playing tennis yesterday when she accidentally hit her left forearm with her own racquet.  You examine her arm and diagnose a simple contusion for which no further treatment is needed.

Problem Points

                     In the example above, the clinical problems would be scored as follows:
Problems Points Example
Self-limited or minor (maximum of 2) 1
Established problem, stable or improving 1  
Established problem, worsening 2  
New problem, with no additional work-up planned (maximum of 1) 3  
New problem, with additional work-up planned 4  
Total Problem Points = 1

In the example, the presence of one “self-limited or minor problem” of a simple arm

contusion adds up to one problem point.    Data Points

                   The data points for the above encounter are scored as follows:
Data Reviewed Points Example
Review or order clinical lab tests 1  
Review or order radiology test (except heart catheterization or echo) 1  
Review or order medicine test (PFTs, EKG, cardiac echo or cath) 1  
Discuss test with performing physician 1  
Independent review of image, tracing, or specimen 2  
Decision to obtain old records 1  
Review and summation of old records 2  
Total Data Points = 0     No points were garnered for review of data. 

Risk

Review of the table of risk shows that this encounter qualifies as Minimal Risk due to the presenting problem of “one self-limited or minor problem.”
Risk Level Presenting Problems Diagnostic Procedures Management Options Selected
Minimal Risk

Requires ONE of these elements in ANY of the three categories listed
One self-limited or minor problem, e.g., cold, insect bite, tinea corporis
  • Laboratory tests
  • Chest X-rays
  • EKG/EEG
  • Urinalysis
  • Ultrasound/Echocardiogram
  • KOH prep
    • Rest
    • Gargles
    • Elastic bandages
    • Superficial dressings
    Given the above information, the MDM Points table would look like this:
    Overall MDM Problem Points Data Points Risk
    Straightforward Complexity 1 1 Minimal
    Low complexity 2 2 Low
    Moderate Complexity 3 3 Moderate
    High Complexity 4 4 High
    In this case, all three components of MDM point toward Straightforward Complexity.  This is the lowest possible level of Medical Decision-Making so it is impossible NOT to qualify for it.

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