Professional E/M PDR Calculator

What is the highest supported PDR Problems level?

Choose the highest level supported by the problems actually addressed in the note.

2 Level 2 - Straightforward 1 self-limited or minor problem. 3 Level 3 - Low 2 or more self-limited or minor problems; 1 stable chronic illness; 1 stable acute illness; or 1 acute uncomplicated illness or injury. 4 Level 4 - Moderate 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; 2 or more stable chronic illnesses; 1 undiagnosed new problem with uncertain prognosis; 1 acute illness with systemic symptoms; or 1 acute complicated injury. 5 Level 5 - High 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or 1 acute or chronic illness or injury that poses a threat to life or bodily function.

Selected Problems level

Choose a Problems level

Choose the highest level supported by the problems actually addressed in the note.

Look for this in the note

Look for the number and complexity of problems that were evaluated, managed, or meaningfully addressed during the encounter.

Boundary check

Pick a level to compare what would move this lower or higher.

What data work is truly documented?

Choose the level supported by the documented data review, ordering, interpretation, and discussion.

2 Level 2 - Straightforward Minimal or no data. 3 Level 3 - Low Limited data: meet at least 1 of 2 categories, such as any combination of 2 unique tests, documents, or orders, or assessment requiring an independent historian. 4 Level 4 - Moderate Moderate data: meet at least 1 of 3 categories, such as any combination of 3 unique tests, documents, or orders; independent interpretation; or discussion of management or test interpretation. 5 Level 5 - High Extensive data: meet at least 2 of 3 categories, including tests/documents/orders, independent interpretation, or discussion of management or test interpretation.

Selected Data level

Choose a Data level

Choose the level supported by the documented data review, ordering, interpretation, and discussion.

Look for this in the note

Look for tests, external documents, independent historian use, independent interpretation, and documented discussion of management or test interpretation.

Boundary check

Pick a level to compare what would move this lower or higher.

What level of management risk does the documentation support?

Choose the level supported by the management decisions and the morbidity risk documented in the encounter.

2 Level 2 - Straightforward Minimal risk of morbidity from additional diagnostic testing or treatment. 3 Level 3 - Low Low risk of morbidity from additional diagnostic testing or treatment. 4 Level 4 - Moderate Moderate risk, such as prescription drug management, social determinants of health that limit care, decision regarding minor surgery with patient/procedure risk factors, decision regarding elective major surgery without identified risk factors, or diagnosis/treatment significantly limited by SDOH. 5 Level 5 - High High risk, such as drug therapy requiring intensive monitoring, decision regarding elective major surgery with identified patient/procedure risk factors, decision regarding emergency major surgery, decision regarding hospitalization or escalation of care, or DNR/de-escalation decisions.

Selected Risk level

Choose a Risk level

Choose the level supported by the management decisions and the morbidity risk documented in the encounter.

Look for this in the note

Look for prescription management, surgery decisions, hospitalization or escalation decisions, intensive monitoring, and other documented management-risk drivers.

Boundary check

Pick a level to compare what would move this lower or higher.

PDR snapshot

Visit Setting Choose one

P / D / R - / - / -

MDM level calculation Throw out the lowest

Professional E/M PDR Calculator

How the calculator works

Start with the visit setting

Score Problems

Score Data and Risk

Determine the supported MDM level

Choose the visit setting

Home / Residence

Hospital / Observation

Nursing Facility

Office / Outpatient

Consultation

Emergency Department

Score Problems, Data, and Risk

What is the highest supported PDR Problems level?

Choose a Problems level

Look for this in the note

Boundary check

What data work is truly documented?

Choose a Data level

Look for this in the note

Boundary check

What level of management risk does the documentation support?

Choose a Risk level

Look for this in the note

Boundary check