Components, subcategories complicate calculation of level

Why This Topic Matters

Correctly understanding MDM affects E/M level selection and documentation review, which can influence coding accuracy and compliance.

Article Sections

1. Medical decision-making overview

   Introduces the role of medical decision-making in evaluation and management services and frames the discussion around level selection.

2. The three MDM factors

   Describes the main component categories used to assess medical decision-making and the importance of documentation in each area.

3. Diagnoses and management options

   Discusses the first MDM component and the broad concept of how problems addressed and documented contribute to complexity.

4. Tests and medical records review

   Covers the second MDM component and the general types of test and record review activity considered in assessment.

5. Risk assessment

   Addresses the third MDM component and the general factors that contribute to risk evaluation.

6. Combining the component levels

   Explains, at a high level, how the component assessments are brought together to determine an overall E/M level.