The 3 elements of MDM: Document tests, outside input for MDM data review and analysis

Why This Topic Matters

The topic affects how office visit documentation supports E/M level selection under the 2021 guidelines. Understanding the scope of the data-review element helps readers judge whether current documentation workflows align with the revised MDM structure.

Article Sections

1. Overview of the 2021 E/M office visit MDM changes

   Introduces the article’s focus on the data-review element within the revised office visit medical decision-making framework. Provides context for why the guidance is being discussed and who it is meant to help.

2. Data review and analysis in the new MDM table

   Summarizes the shift from the previous risk-based table to the new data-review framework. Discusses the general types of documentation and outside information that may be relevant to this element.

3. Levels 1 and 2: Data reporting not required

   Describes the lower-level office visit MDM structure and how the data element is treated there. Identifies the visit levels referenced in this portion of the discussion.

4. Limited, moderate and extensive data analysis

   Outlines the three data-analysis tiers used in the revised MDM table. Explains how the article organizes the documentation categories that apply to each tier.

5. Category-based documentation requirements

   Reviews the broad categories of documentation discussed for tests, records, independent historians, test interpretation, and management discussions. Includes the article’s discussion of how these categories are grouped by MDM level.

6. Editor’s note and source reference

   Provides closing context about related coverage in the series and the source material cited by the publication. Also notes the referenced educational guide and related publisher resources.