Medical decision making and the impact of prescription drug management
Medical decision-making (MDM) is one of the key components used to determine the level of service for Evaluation and Management (E/M) coding. Since 2021, the American Medical Association (AMA) and CMS have emphasized MDM (or time) as the primary factor for selecting E/M levels.
MDM consists of three distinct elements, and the overall level is determined by meeting or exceeding two out of the three:
| Element | What It Means |
|---|---|
| 1. Number and Complexity of Problems Addressed | The number and severity of conditions evaluated during the encounter |
| 2. Amount and/or Complexity of Data Reviewed and Analyzed | Includes labs, imaging, external records, and discussions with other providers |
| 3. Risk of Complications and/or Morbidity or Mortality of Patient Management | Based on medical decisions such as starting medications, ordering procedures, or managing comorbidities |
There are four recognized levels of MDM:
- Straightforward
- Low
- Moderate
- High
Each level reflects increasing complexity in medical thought and patient risk.
Prescription drug management applies to the Risk element of MDM and may support a moderate level of risk when the provider demonstrates active management. This includes:
- Initiating, adjusting, or discontinuing a prescription
- Refilling a medication with clear clinical rationale
- Continuing a drug with documentation tied to the patient’s condition
To qualify for credit under MDM:
- The drug name and dosage must be specified
- The clinical decision (e.g., “continue,” “increase,” “discontinue”) must be documented
- The reason for that decision must be related to the patient’s current condition
While prescription drug management can influence MDM level, it supports the Risk element—a second qualifying element (Problems or Data) must also be met to determine the MDM level.
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