Medical Decision Making And The Marshfield Clinic Scoring Tool FAQ

When assigning an Evaluation and Management Level of Service for a patient encounter, significant factors to consider are the Nature of the Presenting Problem (NOPP) and the complexity of Medical Decision Making (MDM). 

FAQ 1: How is Medical Decision Making (MDM) defined by CPT?

The AMA Current Procedural Terminology (CPT) states: 

"Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:    

  • The number of possible diagnoses and/or the number of management options that must be considered;  
  • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed;  
  • The risk or significant complications, morbidity and/or mortality, as well as co-morbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options".   

FAQ 2: What is Medicare's Take on Medical Decision Making (MDM)?  

The Medicare 1995 E/M Documentation Guidelines essentially reiterates the CPT essentials regarding MDM and adds some illustrations, in part encompassing the following:  

I.          The ancillary studies considered and those ordered such as laboratory studies, x-rays, Special Studies and EKGs.

II.         Any medications considered and those ordered for therapy. This encompasses a broad list including IV, IM, subcutaneous, oral, rectal, topical, eye, ear and other medications including those administered by nebulizers. 

III.       IV fluid administration. 

IV.       Documentation of the presence or absence of relevant findings upon review of old records, including prior admissions and discharge summaries, surgeries, EKGs, lab results, x-ray interpretations, procedures such as cardiac catheterizations, and Special Studies including echocardiograms, CT scans, Ultrasounds, and MRIs. 

V.        Conversations with physicians performing diagnostic studies. 

VI.       Communications with other healthcare providers including the patient's PCP, the admitting or consulting physician, Poison Control professionals, mental health professionals, and EMS or other First Responders. 

VII.      Communication with family members about medical decisions.

VIII.     Direct visualization and independent interpretation of images, tracings, or specimens such as EKG's or X-rays. 

IX.       Patient re-evaluations to determine the patient's response to treatments and interventions and guide further therapy or testing.

FAQ 3: What factors should be considered when determining the number of possible diagnoses and/or management options (DMO)?

The  Medicare 1995 Documentation Guidelines for Evaluation & Management Services, Number of Diagnoses or Management Options (page 11) state:

The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.   

Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems.  

The 1995 Medicare Documentation Guidelines indicate that one can use the number of 'possible Diagnoses and/or Management Options' to determine if DMO is Minimal, Limited, Multiple or Extensive. The terms of Minimal, Limited, Multiple and Extensive are not defined.    

The DMO counted should only include diagnoses, possible diagnoses, and/or management options that are pertinent to the presenting problem or presenting signs or symptoms. Note that 'possible' diagnoses are the same as differential diagnoses. The 1995 Medicare Documentation Guidelines also provide us some clarification on what constitutes a, "management option". "Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications". 

FAQ 4: What is the Marshfield Clinic Scoring Tool?  

In the early 1990's the Marshfield Clinic was a 600 physician multi-specialty, primarily office-based practice in 32 sites throughout Wisconsin. Medicare's 1995 Evaluation & Management Documentation Guidelines were beta-tested at Marshfield Clinic before HCFA released them.  As part of that process, Clinic staff helped their regional Medicare carrier to develop an audit worksheet that included a scoring system for Medical Decision Making (MDM). The score sheets never made it into the official Documentation Guidelines, but are commonly used by physicians, professional coders, and payers to evaluate the complexity of MDM. Below is an excerpt from the Marshfield Clinic Tool: 

Marshfield Scoring- Number of Diagnoses/ Treatment Options


B    X    C

= D

Problems to Examining Physician




Self-limited or Minor

(stable, improved or worsening)

Max = 2



Established Problem (to examiner) stable, improved




Established Problem (to examiner) worsening




New Problem (to examiner) no additional work-up planned

Max = 1



New Problem (to examiner) additional work-up planned







FAQ 5: How should the Marshfield Clinic Scoring Tool for the Number of Diagnoses/Treatment Options be applied to the Emergency Department setting? 

The Marshfield Clinic tool appears to be relevant primarily in the office setting. Unfortunately this model does not apply well to the Emergency Department where a variety of tests and management options are available to be performed during the initial visit. The 1995 Medicare Documentation Guidelines states the Number of Diagnosis and Management Options that must be considered " based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician." Marshfield Clinic created the concept of "additional work-up planned" as a proxy for the Number of Diagnosis and Management Options. This proxy attempts to indicate the complexity of a patient based on the clinician's utilization of diagnostic tests. Therefore using "additional work-up planned" as the linchpin to assign the complexity  of "Number of Diagnoses and/or Management Options" could potentially result in "Limited" "number of Diagnoses and/or Management Options" being elevated to "Extensive" "Number of Diagnoses and/or Management Options". The 1995 Medicare Documentation Guidelines should be kept in mind when assigning Evaluation and Management CPT codes.  

"New Problem" 

In the Marshfield Clinic's audit worksheets, a "new problem" is defined as new to the examining physician.  "The decision making guidelines were designed to give physicians credit for the complexity of their thought processes. Giving a physician more credit for handling a problem he or she is seeing for the first time, even when that problem has been previously identified or diagnosed, is within the spirit of the guidelines". (Bart McCann, MD, former Executive Medical Director HCFA) 

"No Additional Work-up Planned" vs. "Additional Work-up Planned"

"Additional work-up planned" is an attempt by the Marshfield Clinic Tool to quantify the Number of Diagnosis and/or Management Options element of Medical Decision Making (MDM) of the 1995 Medicare Documentation Guidelines. Where does "additional work-up planned" and "no additional work-up planned" appear in the Medical Decision Making portion of the 1995 Medicare Documentation Guidelines? Simple answer- they don't. This scoring perspective was never adopted by CMS or the AMA but remains today as a partially objective methodology for use in determining the complexity level of the MDM. Since the Marshfield Clinic Score Sheet point system is not an official part of the E/M documentation guidelines, there is no regulatory or legislative language that differentiates between these two statements. We look to medical training and practice to help define these terms objectively. 

"Additional work-up planned" refers to information (including diagnostic testing results and consultations) which can be obtained, either during or following the initial E/M encounter, in order to sift through the number of possible diagnoses and/or management options. Consequently when a treating physician in the ED orders diagnostic testing, consultations, or a referral while the patient is in the Emergency Department, "additional work-up" has been planned and performed.

When the Emergency Physician performs "additional work-up" for a patient in the Emergency Department, there has been some confusion whether it is considered "additional work-up planned" or "no additional work-up planned". Neither CPT nor Medicare specify "additional work-up planned" be performed after the Evaluation and Management service. Certainly any additional work-up planned needed for patient care should be performed as soon as practical. Conversely, not recognizing the additional work-up performed in the Emergency Department when determining the complexity of Medical Decision Making would discriminate against Emergency Physicians and penalize them for providing expeditious care that is medically necessary.

In an office setting, the patient visits the practitioner, who may determine that more in-depth information, including diagnostic testing, is necessary. The patient may provide samples right then (same day) and/or arrange for testing (e.g., radiological services) to be performed on a later date, and a follow-up appointment scheduled to review the results and further delineate the diagnosis. The patient may even require a consultation. The usual result is two patient visits with the practitioner over a 1 to 2 week interval, with the interim work-up credited in the initial visit. Sometimes a patient may fail to complete the additional testing and might not even keep the follow-up visit. Even so, the "additional work-up planned" would still be counted because during the initial visit the physician considered multiple diagnoses, management options, and actually ordered additional testing to be done. 

In the Emergency Department, because of the ready availability of comprehensive diagnostic testing, assessments are frequently shortened to a single E/M encounter, with the work-up performed on the same day. It would make no sense to penalize an ED physician for efficiently assessing and managing the patient's presenting medical condition, and assuring the work-up is performed in a timely manner. With regards to Medical Decision Making, the key concept and actual language from the Marshfield Clinic Scoring Tool is that additional work-up was "planned", not whether it was performed on the same day or a later date. 

FAQ 6: How should Emergency Medicine calculate the "Number of Diagnoses and/or Management Options" component of Medical Decision Making (MDM) if using the Marshfield Clinic Tool?

If no additional work-up other than the history and exam is planned during the encounter, then three (3) points are generated for each new problem up to a maximum of one (1) new problem. If additional work-up is planned during the encounter then four (4) points are generated for a new problem. (See table in FAQ #4). 

FAQ 7: How many ancillary tests, consultations, or referrals must be obtained to be considered "Additional Work-up Planned"?

Emergency Medicine physicians obtain a history and perform exams on all patients. Frequently a diagnosis can be determined during these efforts without obtaining any additional ancillary test. At other times the provider might consider a number of possible diagnoses for which ancillary testing is needed. Ancillary studies consist of laboratory studies, radiological studies, EKG's etc. The number and type of diagnostic test employed may be one indicator of the number of possible diagnoses that must be considered. The results will assist with additional therapeutic interventions and ultimately guides the clinician in determining the final dispositions of the patient (admission, transfer or discharge). There is NO mention in the 1995 Medicare Documentation Guidelines of a required minimum number of type of ancillary studies that must be considered or ordered in order to establish a diagnosis. Of course any ancillary studies ordered by the physician should be medically necessary based on the patient's complaint and the diagnoses contemplated.

It is important to remember that the Marshfield scoring system is meant to determine the complexity of the physician's thought process. And while there is no published guidance regarding what type of tests or how many tests are needed to qualify as "additional work-up planned", to assign four (4) points for additional work-up (see FAQ 4), an "extensive" number of diagnosis or management options need to be considered beyond simply assigning four (4) points for any diagnostic test performed in the ED. It may not be appropriate to assign "extensive number of diagnosis or management options" for a patient that solely received a single simple test such as a strep test for a sore throat or single x-ray for an ankle injury.

FAQ 8: How does risk affect Emergency Department Medical Decision Making?

Medical necessity is a major component in payer audits. Payers look to the risk from the presenting problem and/or diagnosis to determine the justification for the emergency department Level of Service. Often payers look only to the final diagnosis rather than the presenting problem, particularly where risk factors, differential diagnoses being considered or other contributing factors are not clearly documented or implied. Thus, providers should correlate the presenting problem, risk factors and final diagnosis to the interventions and diagnostic studies performed to better support he medical necessity of the Emergency Department care provided.

The Documentation Guidelines clarify risk as the risk of significant complications, morbidity, and/or mortality which is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.  These are further outlined as comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality which should be documented.  In addition, the referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied.

For example, on the Documentation Guidelines Risk Table, an acute uncomplicated illness or injury, defined in the guidelines as cystitis, allergic rhinitis or simple sprain is considered to illustrate a "Low" level of presenting problem which correlates to a low level Management Option with over-the-counter drugs or minor surgery with NO identified risk factors.  If, however, the illness or injury requires minor surgery (ex. simple laceration repair with prescription medication, non-displaced fracture requiring splinting, I&D of an abscess, etc.), risk factors are identified and documented, and the problem requires prescription drug management and/or IV fluids with additives such as antibiotics, the Risk level would increase to the "Moderate" level by selection of the moderate level of Management Options. 

The risk table can be downloaded at the link below on page 11 of the 1995 Documentation Guidelines for Evaluation and Management Service found at:


The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date. The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer. For information about this FAQ/ Pearl, or to provide feedback, please contact David A. McKenzie, CAE, Reimbursement Director, ACEP at (972) 550-0911, Ext. 3233 or

Updated 05/24/2017

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