decisionhealth Newsletters, Coder Pink Sheets - 2003 Issue 7 (July)
MDM Part II
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Article Overview
This article focuses on the data reviewed and ordered portion of medical decision-making for evaluation and management encounters. It is written for coding and reimbursement professionals, especially those working in obstetrics and gynecology, and it uses specialty examples to illustrate how documentation is counted at a point-based level. The discussion helps readers understand the kinds of information and test categories that may be considered when assessing complexity.
Why This Topic Matters
Understanding this component of medical decision-making is important because it affects E/M level selection and documentation support. The article provides practical context for coders and physicians who need to evaluate whether documented review and ordering activity is sufficient for the intended service level.
What You Will Learn
- How the data review and ordering component fits into medical decision-making for E/M encounters
- How point-based counting is applied to reviewed or ordered information
- What types of documentation examples are discussed for obstetric and gynecologic practice settings
- How multiple data elements are aggregated when assessing complexity
Who Should Read This
- Medical coders
- Coding auditors
- Reimbursement specialists
- Physicians
- Obstetrics and gynecology practice staff
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