MDM Complexity Decision Tree
Select the highest level reached in each column. The MDM level is determined by the highest level supported by at least 2 of the 3 columns.
Patient type:
Problems
Data
Risk
MDM Complexity
Low
CPT Code
99213
Established patient
Problems:Low
Data:Low
Risk:Low
MDM level = highest tier met by at least 2 of 3 columns
2021 MDM Level Reference
| Level | Problems | Data | Risk | New | Est. |
|---|---|---|---|---|---|
| Straightforward | Minimal | Minimal/none | Minimal | 99202 | 99212 |
| Low | Low | Limited | Low | 99203 | 99213 |
| Moderate | Moderate | Moderate | Moderate | 99204 | 99214 |
| High | High | Extensive | High | 99205 | 99215 |
Level is determined by the highest tier met by at least 2 of the 3 columns: not the average, and not the lowest. 99211 (minimal/nurse visit) does not require physician MDM and is not shown. CPT® is a registered trademark of the American Medical Association.
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