Q&A: Count MDM risk level based on viable treatment options discussed at encounter

Why This Topic Matters

Medical decision-making risk is a key component of E/M leveling, so understanding how documented treatment discussions affect selection can influence coding accuracy, compliance, and payer review outcomes.

Article Sections

1. Question

   Introduces a documentation question about how much discussion is needed for treatment options to count toward medical decision-making risk under the 2023 E/M guidelines.

2. Example encounter documentation

   Presents a sample note showing listed treatment options, a discussion statement, and a conservative recommendation to illustrate the documentation issue being asked about.

3. Answer

   Summarizes the general guidance on encounter-level risk and explains how experts interpret documented treatment discussions in relation to medical decision-making.

4. Expert commentary and documentation concerns

   Includes an expert’s observations about whether certain management options were truly viable or sufficiently discussed, along with broader caution about payer interpretation.