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 will change for codes 99202–99215.

Examples of Moderate MDM:

Codes: New/consult 99204, 99244, Established 99214, Initial hospital 9922, 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.