Mastering the ENM MDM Table: 4 Levels of Medical Decision Making for Medical Coders

In today's video, we are going to learn a very crucial topic or I would say a complicated MDM table of ENM chapter.

Before we dive into the details, let's take a quick look at our today's session agenda. We will understand the

introduction of ENM. What are the key components? We will also explore the different level of medical decision

making. Then we will go step by step through each level starting with straightforward and low MDM then

moderate MDM and wrapping up with high MDM. Let's start with introduction of ENM.

ENM stands for evaluation and management. These services are backbone of medical coding in CPD system. In

simpler words, analysis of patient is called the evaluation and after evaluating providing or managing the

treatment to the patient is called management. When we talk about ENM, we are talking about standard doctor

patient encounters like routine checkups, office visits, preventive visits, counseling, emergency department

services, inpatient care and clinical consultation. Now this ENM CPD code ranges from 99202 to 9949.

What ENM don't include is hands-on procedures. So anything like surgeries, lab test or diagnostic imaging

procedures are not coded with ENM CPT codes. For that we have separate code set.

There are three key components of ENM to select a proper ENM code. First is MDF medical decision making. The name itself

says that clinical decisions made based on presenting problem risk and data during the encounter.

Second is total time based on the cumulative time spent by the health care provider during the encounter related to

patients care. Third is history and examination. This involves gathering the patient's medical history or data

includes chief complaint, history of present illness, past family, social history and performing a physical exam

relevant to the visit. Though there are three components but when it comes to select the ENM level we use either MDM

or time but today we are mainly focusing on MDM. Now here is the most difficult part of

the MDM. How exactly do we break down medical decision making in medical coding? There are four types of label to

determine the MDM straightforward, low, moderate and high. Follow these three main elements together. Problem, data

and risk. The first element is the complexity of the patient's problem. Is it minor issue, major issue or

life-threatening? Second element is data reviewed. How much information, lab work or testing

are you analyzing? Third element is risk. What is the level of risk of complication of morbidity or mortality

involved in managing the patient's condition? Now let's see the four levels. First is straightforward MBM.

This is the baseline. Now you are dealing with minimal problem, minimal data to review and minimal risk to the

patient. In low MDM, a minor stable illness with limited data to review and low overall risk. In moderate MDM, you

have multiple stable illness with exacerbation, a new problem that usually comes with moderate data and moderate

risk. Now, the higher level high MDM is for severe life-threatening conditions where you are managing extensive data to

review and very high treatment risk. There is an important exception to remember. MDM level does not apply to

CPT code 99211 which is a nurse visit code or 992821 since that is emergency department code

doesn't require the presence of qualified healthcare professional. Let's understand each MLM level in

detail. I'm presenting this table using the exact CPT book layout so uh you can easily understand and follow with me.

Only thing I add is some example of condition. Now the most important thing is to determine the overall level of MDM

for an ENM visit. Two out of three core elements which are complexity of problems, data analyzed and risk of

complications. Two out of three elements must meet or satisfies the required criteria. Now

let's look at first level of MDM which is straightforward. Here everything is minimal like minimal problem complexity

where the patient has a self-limited or minor problem like a mild cold, mild skin rash, insect bite or small scrap.

Minimal data means the provider doesn't need to review outside medical records or order lab test. Third element is

risk. Minimal risk of morbidity means the treatment or evaluation has very little or almost no risk of harming the

patient. When all three or at least two of these conditions are met, this service qualifies as straightforward

MDM. Moving up to the low MDM, here the clinical complexity slightly increase. Let's see first element which

is problem complexity. Now you can see there are many conditions mentioned over here but at least one condition needs to

meet uh to consider this element. First is two or more self-limited or minor problems. Second is one stable chronic

illness like controlled hypertension or controlled diabetes. Third is one acute uncomplicated illness or injury uh like

an uncomplicated urinary tract infection or sprained ankle. Fourth, one stable acute illness like acute rhinades.

Fifth, an acute uncomplicated illness or injury which requires hospital inpatient or observation level of cat. For

example, pyonfritis which is kidney infection. Let's see the data to be reviewed and analyzed

element. Here you must meet one out of two categories. Category one where any combination of two components should be

matched among these three components. What are these three three components? Let's have a look. First is review of

prior external notes from each unique source. means reviewing medical records, clinical notes or uh documentation from

a different facility, speciality or external physician. Second component is review of the

results of each unit test means reviewing the result or report of a diagnostic test. clinical lab test,

imaging test like CT scan, MRI that was ordered previously or performed by external provider or external facility.

Third component is ordering each unit test means ordering a new diagnosis uh diagnostic test during the patient

encounter. If you're considering category one to determine low MDM two components should

be met either review of external nodes or test results or order new unique test. Now let's see category two

assessment requiring an independent historian. In simple words, it is getting vital medical history from

someone other than the patient. But what is an independent historian? An independent historian can be anyone, a

parent, a guardian, a spouse who provides history behalf of the patient. To consider a data element, any one

category should be met. Now the third component risk of complications. Low risk of morbidity from additional

diagnostic testing or treatment. Let's understand low risk of morbidity means patient has a very low chance of getting

sick or facing medical complications. When a chart says low risk of morbidity, it means your treatment plan carries

very little chance of harming the patient. Like recommending over the counter meds, writing a prescription for

a standard antibiotic or um ordering routine X-ray because these choices are low danger and that's why low in risk.

Let's talk about moderate embry. To hit a moderate level, your encounter needs to meet or exceed at least two out of

three elements. What is first element? Problem complexity. One or more chronic condition with an exacerbation or flare

up like an amatic or worsening heart failure. Second is managing two or more stable chronic illness for example

control diabetes, control hypertension. Third is one undiagnosed new problem with an uncertain prognosis. For

example, patient has abdominal pain but the cause is still unknown. Fourth is one acute illness with systemic symptom

such as pneumonia or severe flu accompanied by high fever and bodyach. Fifth is one acute complicated injury

for example head injury or complex fracture. If your patient encounter match any single one of these five

condition then you can go for moderate MDM element two data complexity. You must

meet one out of three categories. Category one requires any combination of three components among these four

mentioned below components like reviewing external nodes, reviewing test results, ordering test or gathering

history from a independent historian. Category two independent interpretation of test meaning the provider personally

reviews and interpret the data image or tracing of a test themselves. For example, viewing an actual X-ray image

and interpret the data. Category three, discussion of management or test interpretation, meaning direct

consultation or discussion regarding the patient's care or test results with an external physician or external qualified

health care professional. Now let's see the risk of complication for moderate level. There are four examples that

qualify. First is prescription drug management. This is the most common way to hit moderate risk because uh here

starting adjusting or continuing prescription only medication drug during that encounter satisfies these criteria.

Second is decision regarding minor surgery with risk factors. meaning deciding to perform a minor procedure on

a patient who has added risk factors like underlying health condition or bleeding risk. Third is decision

regarding elective major surgery means recommending or scheduling a major elective surgery for a standard low-risk

patient. Fourth is diagnosis or treatment significantly limited by social determinance of health. when care

or treatment is significantly affected by social factors like food insecurity, homelessness or lack of insurance.

Well, this is all about moderate MDM. Now, let's look at high MDM. First element is problem complexity. There are

only two condition and uh either one of them should be satisfied. First, you must be managing a chronic illness with

a severe exagervation. For example, severe chest pain or one acute or chronic illness injury that

threatens life or bodily function. For example, pulmonary emolism. Second element is data. The categories here are

the same as moderate. That's why I'm not going to explain each of them as I have already explained in previous slide. But

here for high data you must meet two out of three categories instead of just one. In moderate level you must meet only one

category out of three but for high level you must meet two category and uh that is the only difference. For column three

or element three high risk of morbidity there are four examples that qualify. First is drug therapy requiring

intensive monitoring for toxicity. Second is decision regarding elective major surgery without risk factors.

Third is decision regarding emergency major surgery or hospitalization. Fourth is decision regarding parental

controlled substances. Parental means any medication given by needle such as IV uh intramuscular or subcutaneous.

Because IV medications work instantly. They carry a high risk of severe side effects automatically putting them into

a high risk category. And this is all about MDM table. In our upcoming videos, we are going to put all of this into

practice. We will walk through real world clinical scenarios and step-by-step ENM practice questions. If

you found this video helpful, make sure to hit that like button, subscribe to the channel, and turn on notification so

uh you don't miss our upcoming practice question session. Thank you for watching the video.