When it comes to Medical Decision Making (MDM), not all injuries are created equal. One key distinction providers must document clearly is whether an injury is uncomplicated or complicated—a difference that significantly affects MDM scoring.
Acute Uncomplicated Injury: The Basics
Per AMA CPT® guidelines, these are recent, low-risk injuries with expected full recovery and no long-term impact.
Examples:
- Minor lacerations
- Simple sprains
- Closed, non-displaced fractures without complications
They typically support low MDM—assuming care and risks are minimal.
Documentation Tips:
- Describe the injury (depth, size, location)
- Note basic treatment and patient education
What Makes an Injury “Complicated”?
A complicated injury poses higher risks or requires more intensive management. There’s no single definition, but clinical and coding authorities (AAPC, CMS, AAFP, etc.) point to factors like:
- Neurovascular risk
- Deep or layered tissue involvement
- Delayed healing due to comorbidities
- Need for advanced imaging, procedures, or referral
- Head trauma with symptoms concerning for concussion, especially if there’s loss of consciousness, confusion, or need for neurologic evaluation
These factors elevate the MDM to moderate or high, depending on context.
Documentation Tips:
- Spell out complicating factors
- Detail the decision-making and any additional workup
- Detail physical or other exam elements that must be considered for assessment and management
- For concussions: clearly note if there was LOC, neuro symptoms, or return-to-play instructions
It’s Not Just the Diagnosis
Diagnosis codes don’t tell the whole story. A laceration may code the same whether it’s superficial or involves fascia and layered closure. A concussion may code similarly whether or not LOC occurred. From an MDM standpoint, how you manage the problem is what matters.
Final Takeaway
Labeling an injury “complicated” requires clear, clinical justification—but if your management involves more risk, more time, or more thought, it probably qualifies. Be specific. Coders and auditors can’t read between the lines.
Next in the Series
August 26 – MDM Demystified: Data – Labs, Imaging, and External Records
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