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

Article Overview

This Q&A article explains a common documentation question under the 2023 E/M medical decision-making framework: how to think about risk when multiple treatment options are listed in an encounter note, but only some are clearly discussed and carried forward in the plan. It is relevant to physicians, coders, auditors, and compliance staff who review office and outpatient E/M documentation. The article focuses on general risk assessment concepts, the role of documented discussion, and practical concerns about how payers may view viable versus non-viable management options.