Medical decision-making: Know how to keep it on the level

Why This Topic Matters

Accurate MDM selection affects how evaluation and management services are supported in documentation and reviewed in coding workflows. Understanding the general structure of MDM helps coding professionals apply documentation more consistently and recognize what types of information contribute to the overall level.

Article Sections

1. Introduction

   Introduces the topic of medical decision-making and explains that the article will define key terms and summarize a simplified selection approach.

2. What is MDM?

   Defines medical decision-making and distinguishes it from other parts of the encounter documentation. It also introduces the types of services that may involve MDM.

3. The levels of MDM

   Lists the general levels used in MDM and explains that each level is built from multiple components.

4. Component 1: Number and complexity of problem addressed

   Describes the first MDM component and the broad categories used to assess the problems addressed during the encounter.

5. Component 2: Amount and/or complexity of data to be reviewed and analyzed

   Reviews the second MDM component and outlines the general kinds of data-related activities considered in the framework.

6. Component 3: Risk of complications and/or morbidity or mortality of patient management

   Explains the third MDM component and describes the broad categories of management risk considered in MDM selection.

7. Determining the level of MDM

   Summarizes how the three components are combined to determine the overall level of MDM.