CodeLevel of MDM (Based on 2 out of 3 Elements of MDM)Elements of Medical Decision Making
Number and Complexity of Problems AddressedAmount and/or Complexity of Data to be Reviewed and Analyzed
*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.		Risk of Complications and/or Morbidity or Mortality of Patient Management
99211N/AN/AN/AN/A
99202
99212		StraightforwardMinimal

  • 1 self-limited or minor problem

Minimal or noneMinimal risk of morbidity from additional diagnostic testing or treatment
99203
99213		LowLow

  • 2 or more self-limited or minor problems

    or

  • 1 stable chronic illness

    or

  • 1 acute, uncomplicated illness or injury

Limited
(Must meet the requirements of at least 1 of the 2 categories)
Category 1: Tests and documents
Any combination of 2 from the following:

  • Review of prior external note(s) from each unique source*

  • Review of the result(s) of each unique test*

  • Ordering of each unique test*


or
Category 2: Assessment requiring independent historian(s)
(For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high)		Low risk of morbidity from additional diagnostic testing or treatment
99204
99214		ModerateModerate

  • 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment

    or

  • 2 or more stable chronic illnesses

    or

  • 1 undiagnosed new problem with uncertain prognosis

    or

  • 1 acute illness with systemic symptoms

    or

  • 1 acute complicated injury

Moderate
(Must meet the requirements of at least 1 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
Any combination of 3 from the following:

  • Review of prior external note(s) from each unique source*

  • Review of the result(s) of each unique test*

  • Ordering of each unique test*

  • Assessment requiring independent historian(s)


or
Category 2: Independent interpretation of tests

  • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)

    or


Category 3: Discussion of management or test interpretation

  • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)

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

99205
99215		HighHigh

  • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

    or

  • 1 acute or chronic illness or injury that poses a threat to life or bodily function

Extensive
(Must meet the requirements of at least 2 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
Any combination of 3 from the following:

  • Review of prior external note(s) from each unique source*;

  • Review of the result(s) of each unique test*;

  • Ordering of each unique test*;

  • Assessment requiring independent historian(s)


or
Category 2: Independent interpretation of tests

  • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);


or
Category 3: Discussion of management or test interpretation

  • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)

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