Diagnosis, treatment options and MDM

Why This Topic Matters

Understanding how MDM is assessed helps support consistent E/M code selection and documentation. The article is relevant for teams reviewing office visit coding and physician documentation quality.

Article Sections

1. Medical decision-making and E/M level selection

   Introduces MDM as a factor in evaluation and management visit coding and describes its relationship to visit level selection. It also frames the discussion for coders and clinicians reviewing documentation support.

2. The three aspects of MDM

   Summarizes the broad components used to evaluate MDM. The section explains how these components relate to moderate and high complexity at a general level.

3. New and established patient E/M visits

   Discusses how MDM contributes to code selection for new and established patient visits. It places the topic in the context of overall E/M component requirements.

4. Diagnosis and treatment options in ObGyn

   Focuses on one part of MDM within an ObGyn specialty context. The section explains the general idea of considering diagnoses and treatment choices during an encounter.

5. Point system for complexity

   Describes a point-based approach used to assess complexity of diagnostic and treatment considerations. The section includes general examples of problem types and how they relate to complexity scoring.

6. Counting problems toward the total

   Explains how problems are tallied within the scoring approach and how totals are interpreted at a high level. It also notes that assessment can involve some subjectivity.

7. MDM as one part of the overall determination

   Emphasizes that diagnosis and treatment options are only one component of MDM. The section places this factor in the broader context of documentation review.