Chiropractic E/M Coding Guide Part 4: Coding Based on Medical Decision Making
In this fourth and final part of our E/M coding series, we focus on medical decision making (MDM) as another method for selecting the appropriate evaluation and management code.
Unlike code selection based on time, MDM requires you to consider the complexity of the problems addressed, the data reviewed and analyzed, and the risk associated with patient management. Understanding these three elements can make E/M code selection more straightforward and support clear, defensible documentation.
E/M Code Selection Based on Medical Decision Making (MDM)
Evaluation and management code selection should be based on time or medical decision making (MDM). MDM is a bit more involved than time, but can be quantified and supported with clear documentation, making it a very defensible option.
A framework is provided to guide a practitioner to the correct code. There are three elements of MDM:
The number and complexity of problems that are addressed during the encounter.
The amount and/or complexity of data to be reviewed and analyzed.
The risk of complications and/or morbidity or mortality of patient management.
Put more simply:
Problems (what kinds of problems does the patient present with, and how many of them are being handled by the provider?)
Data (how much history from others, information from diagnostic tests, or records from other providers must be ordered or reviewed?)
Risk (how risky is the treatment or diagnostic tests that this patient needs?)
The official MDM table provides detailed guidance on how these three elements come together to determine the appropriate code. Below are simplified tables for 99202/99212, 99203/99213, and 99204/99214.
Level 2 E/M: Straightforward MDM
| Level of MDM | Problems | Data | Risk |
|---|---|---|---|
| Straightforward |
Minimal 1 self-limited or minor problem |
Minimal or none | Minimal risk of morbidity from additional diagnostic testing or treatment |
To qualify for a straightforward level of MDM, which is required for a level 2 E/M service (99202 for new or 99212 for established), the problems should be minimal, the data may be minimal or absent, and the risk should also be minimal. To use MDM, two of the three elements must be met, and time is not a factor.
Sample documentation to support a level 2 (99202/99212) E/M that includes Problems and Risk (Data isn’t necessary since only 2 of the three elements are required) might be:
“The Medical Decision Making at this encounter is straightforward. The problem appears to be self-limited or minor, as it is transient and unlikely to permanently alter the patient's health status. There appears to be a minimal risk of morbidity or functional impairment of substantial duration."
The definition of “self-limited or minor” for this statement was taken straight from the official guidelines, as was the definition of “morbidity.” This documentation is not required, but it would make a reviewer’s job much easier if they see this kind of statement and can line it up with the E/M Guidelines for a “straightforward” level of MDM.
Level 3 E/M: Low MDM
The table is a bit more complicated for level 3 (99203/99213) exams. This is an abbreviated version):
| Level of MDM | Problems | Data | Risk |
|---|---|---|---|
| Low |
Low
|
Limited
OR
|
Low risk of morbidity from additional diagnostic testing or treatment |
The definitions for each of these items, along with much more detail for the “Data” column, can be found in the official guidance mentioned above.
Sample documentation to support a level 3 (99203 or 99213) E/M that includes Problems and Risk (but not Data) might be:
“The Medical Decision Making at this encounter is low. The problem appears to be acute and uncomplicated because it is recent, likely short-term, and full recovery without functional impairment is expected. There appears to be a low risk of morbidity or functional impairment of substantial duration."
This example supports a “low” level of MDM, which is required for a 99203 or 99213. The definition of an “acute and uncomplicated problem,” which is one of the five choices in the “Problems” column, is taken from the guidelines, as is the definition of “morbidity.”
Level 4 E/M: Moderate MDM
A level 4 exam would be much rarer in a chiropractic setting, as shown in the table below.
| Level of MDM | Problems | Data | Risk |
|---|---|---|---|
| Moderate |
Moderate
|
Moderate
|
Moderate risk of morbidity from additional diagnostic testing or treatment |
The full definitions of the problems listed here can be found in the official guidelines, but many of them are not the kinds of things that present for care in a chiropractic office. The data analysis required for a level 4 is far more extensive than is necessary for most musculoskeletal complaints. The examples of things that are considered “moderate” for the risk are as follows:
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
Managing prescriptions and surgeries is outside the scope of practice for most chiropractors, and social determinants of health, such as homelessness, may affect typical chiropractic care, but this would likely be the exception, not the rule.
Sample documentation to support a level 4 (99204 or 99214) E/M that includes Problems and Risk (and ignores Data) might be:
“The Medical Decision Making at this encounter is moderate. The problem appears to be acute and complicated because there are multiple treatment options and requires evaluation of other body systems. There appears to be a moderate risk of morbidity or functional impairment of substantial duration."
The problem chosen here uses verbiage from the definition found in the official guidelines. The intention is to make these terms highly recognizable to someone familiar with the rules. As a reminder, none of this documentation is specifically required, but it is offered here as a suggestion to create a defensible record should it be challenged.
FAQs
-
There are three elements of MDM: the number and complexity of problems addressed, the amount and/or complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality associated with patient management.
-
To use MDM, two of the three elements must be met, and time is not a factor. For chiropractic, the Data element is the one that would most often not need to be included.
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Yes. E/M codes may be selected based on either time or medical decision-making.
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A low level of MDM is required for a 99203 or 99213.
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A level 4 exam would be much rarer in a chiropractic setting. The problems, data analysis, and risks associated with a level 4 MDM are generally more extensive than necessary for most musculoskeletal complaints.
Conclusion
In conclusion, understanding and effectively utilizing Evaluation and Management (E/M) codes is essential for chiropractic physicians to ensure proper documentation, compliance, and reimbursement. With updated guidelines that simplify the requirements, chiropractors can focus on patient care while maintaining defensible records. By understanding the differences between new and established patients, leveraging time or medical decision making (MDM) for code selection, and adhering to medically appropriate standards, providers can navigate the complexities of E/M coding with confidence.
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This is the final part of our 4-part E/M Coding Mastery Series. Check out the other parts below:
Part 1: New vs. Established Patients (99201–99215 Explained)
Part 4: Coding Based on Medical Decision Making
