Understanding E/M: Medical decision-making: Know how to keep it on the level

Why This Topic Matters

Correctly understanding medical decision-making is central to accurate E/M code assignment and consistent documentation review. The article helps readers orient themselves to the broad structure of the topic before consulting more detailed guidance.

Article Sections

1. What is MDM?

   Introduces the concept of medical decision-making and its place in E/M coding. It also distinguishes it from other parts of a patient encounter.

2. CPT codes that include MDM

   Lists the main CPT service families discussed in the article that rely on medical decision-making. The section provides scope for outpatient, inpatient, emergency, facility, and care management services.

3. The levels of MDM

   Summarizes the overall levels used in medical decision-making selection. This section frames the hierarchy used throughout the rest of the article.

4. Component 1: Number and complexity of problem addressed

   Explains the first component used in assessing medical decision-making and discusses broad problem-severity concepts. It covers the general relationship between condition complexity and level selection.

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

   Describes the second component involved in medical decision-making and outlines broad categories of data activity. It also introduces the related terminology used in this area.

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

   Covers the third component used in evaluating medical decision-making and the general concept of management risk. The section focuses on broad risk considerations in patient care.

7. Determining the level of MDM

   Explains how the three components are combined to arrive at an overall level. The section presents the article’s general framework for comparing component levels.