Leveling: Consider This Leveling Advice for MDM

Why This Topic Matters

MDM leveling affects E/M code selection, and ambiguous documentation can make it difficult to support the appropriate level of service. Understanding the broad factors discussed here can help reviewers evaluate whether the record reflects the encounter’s overall complexity.

Article Sections

1. Evaluate all available information when determining risk

   Introduces the article’s focus on evaluating encounter documentation to support MDM level selection. Sets up the overall discussion of risk, data, and clinical judgment in E/M coding.

2. Know That a Patient May Refuse a Test

   Discusses how a refused test can affect the review of encounter documentation and MDM analysis. The section focuses on documenting the provider’s thought process and the broader implications for the care plan.

3. Understand Elements of Drug Management

   Reviews prescription drug management in the context of MDM and compares general CPT guidance with Medicare-oriented commentary. It emphasizes documenting medication management decisions and the overall encounter context.

4. Define Risk Carefully

   Explains how to think about risk in MDM when evaluating a patient for surgery or similar decision-making. The section considers documentation context, comorbid conditions, and how different encounter elements interact.