General Surgery Coding Alert - 2015 Issue 1
Key Elements: Secure an MDM for an Accurate E/M Level
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Article Overview
This article is a practical coding resource for professionals who need to understand how medical decision making is evaluated for E/M services. It focuses on a point-based framework for the major MDM components, how risk is considered using CMS risk guidance, and how the pieces are combined to support an E/M level. The discussion is aimed at coders, auditors, and clinicians who document and review encounter complexity.
Why This Topic Matters
Accurate MDM assessment is central to selecting the correct E/M level and avoiding overcoding or undercoding. Understanding the framework used in the article can help support more consistent documentation review and coding alignment.
Article Sections
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Assign Points to 3 MDM Components
Introduces the three broad components used to evaluate medical decision making and describes the overall point-based approach discussed in the article.
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Count Diagnoses and Management Options
Covers the first MDM component and explains how diagnosis and management status categories are organized within the point system.
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Add Up the Data Elements
Reviews the second MDM component and describes the types of data and review activities considered in the point calculation.
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Determine Level of Risk
Discusses the third MDM component and the use of CMS risk guidance to assess encounter risk at a broad level.
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Pull it All Together to Get MDM
Explains how the three MDM components are combined to determine the overall medical decision making level.
What You Will Learn
- How the article’s point-based framework organizes the main components of medical decision making
- What broad types of documentation and review activities are considered in the MDM assessment
- How encounter risk is incorporated into the overall evaluation process
- How the article describes combining component levels to support an E/M service level
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physicians
- Clinical documentation improvement staff
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