decisionhealth Newsletters, Coder Pink Sheets - 2007 Issue 7 (July)
3 subcategories complicate MDM determination
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Article Overview
This article discusses medical decision-making (MDM) as it relates to evaluation and management (E/M) coding, with a focus on the three major components used to assess complexity. It is intended for coders and clinicians who need a clearer understanding of how MDM is evaluated at higher E/M levels and how the framework is applied in general coding review.
Why This Topic Matters
Correctly understanding MDM is important for supporting accurate E/M level selection and documentation review, especially when more complex services are involved.
Article Sections
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Medical decision-making and E/M level selection
Introduces the role of medical decision-making in evaluation and management coding and explains why it is important for higher-level services.
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The three components of MDM
Summarizes the broad categories used to evaluate MDM and how they contribute to overall complexity.
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Number of diagnoses or treatment options
Discusses the first MDM component and the general approach used to assess diagnostic and treatment complexity.
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Amount and complexity of data
Covers the second MDM component and the review of information used to support the service level.
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Risk
Explains the third MDM component and its relationship to the overall assessment of service complexity.
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Applying the three subcategories together
Describes the need to review the components together when determining the overall level of medical decision-making.
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MDM points for diagnosis and treatment
Presents a point-based framework related to the diagnosis and treatment category of MDM.
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MDM points for data review
Presents a point-based framework related to review and analysis of data in MDM.
What You Will Learn
- How MDM fits into E/M level selection
- The major components used to assess MDM complexity
- How general point-based frameworks are used to organize MDM review
- How the article frames the relationship between MDM, history, and exam
Who Should Read This
- Medical coders
- Coding auditors
- Physician practices
- Interventional specialists
- Revenue cycle staff
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