DecisionHealth, DecisionHealth - 2023 Issue 7 (July)

Count MDM risk level based on viable treatment options discussed at encounter

Question: When selecting the level of risk to code based on medical decision-making (MDM), the 2023 E/M guidelines state that you can count the risk of treatment options that were discussed but ultimately not chosen. We are wondering how much discussion must be documented in order to count toward risk? For example, our providers will list the treatment options and then document what was recommended and decided...

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