Low risk of morbidity from additional diagnostic testing or treatment
CMS Criteria for MDM-Based Coding
Presenting Problems:
Two or more self-limited or minor problems
One stable chronic illness
Acute uncomplicated injury or illness
Diagnostic Procedures:
Physiologic tests not under stress
Non-cardiovascular imaging studies with contrast
Superficial needle biopsy
ABG
Skin biopsies
Management Options:
Over-the-counter drugs
Minor surgery w/o risk factors
Physical/Occupational Therapy
IV fluids without additives
Function-Oriented Criteria for WC Injury or Illness 📄
Presenting Problems:
Two or more self-limited or minor problems
One stable chronic condition
Acute uncomplicated injury or illness
WC Diagnostic Procedures:
Physiologic tests not under stress (e.g. spirometry)
Imaging studies other than X-rays, without contrast
Allergy or skin patch testing
Management Options:
Over the counter drugs
Work restrictions addressing only the injured body part
Splints
Physical therapy
Occupational therapy
Counseling on safe activities and self-care
Other
Moderate risk of morbidity from additional diagnostic testing or treatment
CMS Criteria for MDM-Based Coding
Presenting Problems:
Two stable chronic illnesses
One chronic illness with mild exacerbation or progression
Undiagnosed new problem with uncertain prognosis
Acute complicated injury
Diagnostic Procedures:
Physiologic tests under stress (e.g., cardiac stress test, fetal contraction stress test)
Diagnostic endoscopies, with no identified risk factors
Deep needle, or incisional biopsies
Cardiovascular imaging studies, with contrast, with no identified risk factors (e.g., arteriogram, cardiac catheterization)
Obtain fluid from body cavity (e.g., LP/thoracentesis)
Management Options:
Minor surgery, with identified risk factors
Elective major surgery w/o risk factors
Prescription drug management
Therapeutic nuclear medicine
IV fluids, with additives
Closed treatment of fracture or dislocation, without manipulation
Function-Oriented Criteria for WC Injury or Illness 📄
Presenting Problems:
Two stable chronic conditions
One chronic condition with mild exacerbation or progression
Undiagnosed new problem with uncertain prognosis
Acute complicated injury
Delayed injury recovery compared to estimated duration of disability
Use of opioids past 30 days
Work relationship problems
Already off work, less than 4 weeks
WC Diagnostic Procedures:
Nerve testing
Bone scans
Imaging studies with contrast
Functional capacity evaluation
Physiologic tests under stress (e.g., cardiac stress test, pulmonary exercise test)
Management Options:
Work restrictions addressing multiple body parts/functions
Management of work accommodations, hazard abatement, equipment or ergonomic modifications
Addressing environmental tests
Joint aspiration or epidural injection
Prescription drug management
Closed treatment of fracture or dislocation, without manipulation
Counseling on self-management for pain, disability risk factors, activities to support return-to-work
Diagnosis/treatment significantly limited by social determinants of health
Other
High risk of morbidity from additional diagnostic testing or treatment
CMS Criteria for MDM-Based Coding
Presenting Problems:
One or more chronic illness, with severe exacerbation or progression
Acute or chronic illness or injury, which poses a threat to life or bodily function
An abrupt change in neurological status
Diagnostic Procedures:
Cardiovascular imaging, with contrast, with identified risk factors
Cardiac EP studies
Diagnostic endoscopies, with identified risk factors
Discography
Management Options:
Elective major surgery with identified risk factors
Emergency major surgery
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision not to resuscitate, or to de-escalate care
Function-Oriented Criteria for WC Injury or Illness 📄
Presenting Problems:
One or more chronic illness, with severe exacerbation/progression
Acute or chronic illness or injury, which poses a threat to life, bodily function or return to work
Presence of more than one disability risk flag
Use of opioids past 60 days
Off work more than 4 weeks
Job/modified work not available
WC Diagnostic Procedures:
Methacholine challenge
Management Options:
Detailed determination of overall functional abilities related to permanent restrictions
Collaboration with vocational rehabilitation
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity (including chronic opioid management or detoxification)
Work-focused cognitive behavioral therapy
Functional restoration program
Multidisciplinary pain mgmt. program
Hospitalization
Other
Data
Level:
Category
1:
Tests,
documents, or
independent historian(s)
Review of
prior
external note(s) from each
unique source (not your
own
notes)
Review of the result(s) of each
unique test (Not
previously
used
in
prior
visit(s))
Ordering
of each
unique test
Assesment
requiring an independent historian(s)
Category
2:
Independent
interpretation of tests
Independent interpretation of a test performed by
another
physician/other qualified healthcare proffessional (not
separately
reported)
Category
3:
Disscussion of
management or test interpretation
Disscussion of management or test interpretation with
external
physician/other qualified health care
professional/appropriate source
(not seperately reported)