1. Which three elements are used to determine an MDM level?
Answer: B — Problems, data, and risk.
Why: MDM uses the number and complexity of problems addressed, the amount and/or complexity of data reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management.
2. True or false: For office/outpatient E/M visits, the extent of history and physical exam determines the code level.
Answer: False.
Why: For the office/outpatient E/M framework used in this worksheet, the level is selected based on medical decision making or time when the applicable requirements are met. History and examination should be medically appropriate, but their extent does not determine the MDM level.
3. How many of the three MDM elements must meet or exceed a level?
Answer: B — Two.
Why: Apply the two-of-three rule. At least two of the three MDM elements must meet or exceed the level selected.
4. True or false: Every diagnosis listed in the medical record automatically counts as a problem addressed.
Answer: False.
Why: Count problems that are actually addressed during the encounter. A condition appearing in the record does not automatically count merely because it is listed.
5. Prescription drug management is generally an example of which risk level?
Answer: C — Moderate.
Why: In the MDM risk examples used for this lesson, prescription drug management is an example of moderate risk.
Case Challenge
Scenario: Established patient. Type 2 diabetes is worsening; today's A1c is 9.2%. Hypertension is stable. The clinician increases the patient's prescription diabetes medication and schedules follow-up. No data element is counted for this exercise.
| MDM Element | Level | Rationale |
|---|---|---|
| Problems addressed | Moderate | Worsening diabetes supports a chronic illness with exacerbation/progression. |
| Data reviewed/analyzed | Minimal / none | The worksheet specifically states that no data element is counted for this exercise. |
| Risk of patient management | Moderate | The clinician increases prescription medication: prescription drug management. |
7. What is the overall MDM level, and why?
Answer: Moderate MDM.
Why: Problems are Moderate and Risk is Moderate. Two of the three elements meet Moderate, so the overall MDM is Moderate.
8. For an established office/outpatient patient, which code would this MDM level support?
Answer: C — 99214.
Why: For the established office/outpatient case in this exercise, Moderate MDM supports 99214.
Educational use only. Always verify code selection using the current-year CPT code set, official guidance, encounter documentation, and applicable payer policy.