E/M Coding: Get A Handle on the MDM Level of Risk Data Points

Why This Topic Matters

Accurate MDM scoring affects emergency department E/M level selection, documentation support, and audit defensibility. The article highlights an area where coders may encounter differing interpretations and shows why consistent local policy and clear documentation are important.

Article Sections

1. Look to These Charts for Guidance

   Introduces the MDM framework used in emergency department E/M coding and summarizes the broad components considered in common scoring approaches. It also notes the role of risk assessment guidance in the overall process.

2. Putting it all Together

   Explains how the component scores are combined at a high level to determine overall MDM complexity. It also discusses the relationship between complexity levels and the need for consistent application across settings.

3. Be Careful When Adding Points

   Focuses on documentation of diagnostic test ordering and independent review in the context of MDM data review. The section compares general professional guidance with payer perspective on chart documentation and review credit.