Medical Decision Making (MDM) isn’t always high-stakes—and that’s okay. Many visits fall under low complexity, especially those involving self-limited problems or stable chronic conditions. But to support compliant billing, providers need clear, specific documentation.
Let’s break down what these terms mean and how they impact MDM scoring.
What Qualifies as Low-Complexity?
According to AMA, low MDM may include:
- One or more self-limited or minor problems, or
- One stable chronic illness
Self-Limited or Minor Problem
Defined as:
“A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.”
Examples:
- Viral URI
- Minor rash
- Insect bite
- Seasonal allergies
These issues are temporary, but still require clinical judgment, patient education, and safety netting.
Tip: Note exam findings, patient instructions, and any red flags considered that may affect management or care.
Stable Chronic Illness
Defined as:
“A problem with an expected duration of at least one year… that is controlled and not worsening.”
Examples:
- Hypertension with normal BP today
- Well-managed diabetes
- Depression in remission
- Controlled asthma
Stable ≠ inactive. Monitoring, meds, labs, and counseling still count toward MDM.
Documentation Tip: From a coding perspective, a condition should not be called “stable” unless it is truly at goal for that specific patient. For example, if a diabetic patient’s A1c is still above their target—even if it’s unchanged from last visit—it may not meet the definition of stable. The nuance matters.
Tip: Document disease status, treatment adherence, and ongoing management—no change doesn’t mean no decision-making.
Why Documentation Matters
According to AAFP, AHIMA, AAPC, CMS, and others, under-documentation is common for low-complexity visits. Tips to avoid under-documentation:
- Be specific about the condition and clinical impression
- Show your thought process, even if no changes are made
- Use language that reflects active management
Impact on MDM Scoring
- 1 self-limited problem = Straightforward
- 2+ self-limited problems = Low
- 1 stable chronic illness = Low
Clear documentation helps ensure the encounter is scored—and reimbursed—appropriately.
Bottom Line
Low-complexity problems are still high-value care.
Whether you’re treating a cold or managing chronic hypertension, specific, clear documentation is key to accurate coding and compliance.
Next in the Series:
August 21 – Acute Complicated Injury – How It Differs from Acute Uncomplicated
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