Use three MDM components to help assign the best E/M level

Why This Topic Matters

Understanding the structure of medical decision-making helps support consistent E/M level selection and documentation review. This matters for practices that want to evaluate whether a chart supports a higher-complexity visit without overstepping coding guidance.

Article Sections

1. Take a closer look

   Introduces the three major components used to evaluate medical decision-making and discusses how each broad factor contributes to overall E/M assessment.

2. Number of diagnoses or treatment options

   Reviews the first component of medical decision-making and explains how diagnostic and management considerations are weighed in chart review.

3. Amount and complexity of data

   Covers the second component of medical decision-making and discusses review of records, test information, and related data sources.

4. Risk

   Addresses the third component of medical decision-making and describes the broad categories used to assess patient and procedure-related risk.

5. The tricky part

   Summarizes how the components are considered together when determining overall medical decision-making and how that fits into E/M selection.

6. MDM points for diagnosis and treatment

   Provides a point-based reference for comparing levels of diagnostic and treatment complexity.

7. MDM points for data review

   Provides a point-based reference for comparing types of data review and information gathering.