Which scenario would typically result in the highest MDM score?

The scenario involving new problems for the patient typically results in the highest MDM (Medical Decision Making) score because it indicates a greater level of complexity and risk requiring the clinician to devote considerable effort to evaluate, diagnose, and possibly treat these conditions. In medical coding, the MDM score is influenced by factors such as the number of diagnoses or management options, the amount and complexity of data reviewed, and the risk of complications or morbidity associated with the patient's presenting problems.

When a patient presents with new problems, the physician must engage in a higher level of analysis, which may include ordering tests, ruling out differential diagnoses, and considering various treatment options. This increased level of clinical decision-making complexity directly correlates with an enhanced MDM score.

In contrast, stable chronic conditions or routine follow-up visits usually suggest a lower level of decision-making complexity since the patient’s health status is relatively unchanged and requires less intensive management. Long-term management of a known illness may involve some complexity, but it often includes established treatment protocols and predictable outcomes, which generally yield lower MDM scores compared to new problems that need to be addressed.