How to use three categories of MDM to assign the best E/M level

Why This Topic Matters

MDM is a core part of E/M level selection, so understanding how it is organized can help readers better evaluate documentation and support compliant coding decisions.

Article Sections

1. Introduction

   Introduces the role of medical decision-making in E/M coding and explains why it can be challenging to evaluate.

2. The three categories of MDM

   Summarizes the major components used to assess medical decision-making under the CPT E/M guidelines.

3. Number of diagnoses or treatment options

   Discusses how diagnostic considerations and treatment options are reviewed as part of MDM assessment.

4. Amount and complexity of data

   Covers the evaluation of records, tests, and other information that contribute to the data component of MDM.

5. Risk

   Reviews the risk component of MDM and broad categories of patient and procedure-related risk.

6. The tricky part

   Explains the relationship among the MDM subcategories and the overall E/M selection process.

7. MDM points for diagnosis and treatment

   Presents a point-based framework used for assessing diagnosis and treatment complexity.

8. MDM points for data review

   Presents a point-based framework used for assessing the review of data and related information.