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Moderate or High MDM – General Surgery

Accurately select the level of medical decision making, using the 1995 and 1997 Documentation Guidelines. This article provides examples of moderate and high MDM. For more information on the requirements for medical decision making, see this article.

Remember, in 2021, the definition of MDM changed for codes 99202–99215.

Examples of Moderate MDM:

Codes: Consult, 99244,  Initial hospital 99222, Initial OBS 99219, 99235, ED 99284

  • Patient presents with a breast lump. Biopsy and ultrasound planned.
  • Patient with moderate exacerbation of Crohn’s disease.
  • Patient with no risk factors assessed in ED, needs surgery for a hernia repair, scheduled within the next few weeks.
  • 50-year-old male seen in consultation for rectal bleeding, weight loss, abdominal pain, with no chronic problems. Scheduled for colonoscopy in the near future.
  • 17-year-old seen in ED, CT scan and lab work done, called to ED, patient with appendicitis, taken to surgery.

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Last revised January 4, 2021 - Betsy Nicoletti
Tags: Documentation Guidelines, general surgery, MDM, medical decision making

Looking for training on the new E/M Guidelines for 2021?

"Documentation Essentials for Codes 99202-99215 in 2021" is now available!

Take the two hour course on-demand, or sign up for one of our live events with Q&A.

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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