Per CPT guidelines, there are three measurements for selecting the level of medical decision making (MDM)**:

• The number of possible diagnoses and/or the number of management options that must be considered.
• The amount and/or complexity of medical records, diagnostic tests and /or other information that must be obtained, reviewed and analyzed.
• The risk of significant complications, morbidity and/or mortality–as well as co-morbidities–associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

**Note: For workers’ compensation purposes, the MDM must be related to the injury of record.

There are four types of medical decision making:

Straightforward – Minimal management options; minimal or no data to review; minimal risk of complications and/or morbidity or mortality.

Low Complexity – Limited management options; limited data to review; low risk of complications and/or morbidity or mortality.

Moderate Complexity – Multiple management options; moderate data to review; moderate risk of complications and/or morbidity or mortality.

High Complexity – Extensive management options; extensive data to review; high risk of complications and/or morbidity or mortality.

When choosing the appropriate level of E/M the following guidelines apply:

New patient – requires all three key components for level selection.

Established patient – requires two of three of the three key components for level selection.

Time – Another component that may be used to select a level is time. Per CPT guidelines, when counseling and/or coordination of care dominates more than 50 percent of the approximate time allocated to each level (see your CPT manual) of face-to-face time with the patient, then time may be considered the key or controlling factor for selecting a level of service. Medical necessity must be met when using time as a key factor and the documentation must clearly support how that time was utilized. Just stating that “more than 50 percent of time was spent in counseling and coordination of care” is not sufficient.

Moderate Conscious Sedation

When moderate conscious sedation services (codes 99144 and
+99145) are provided by the same physician performing a diagnostic or therapeutic service (that the sedation supports), an independently trained observer is required to assist in the monitoring of the patient’s level of consciousness and physiological status. The presence of the observer must be documented in the procedure record or in the sedation record submitted.