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Department of Neurology

 

MEDICAL DECISION MAKING


The key to E/M coding is to first determine the level of medical decision making (MDM). MDM is determined by looking at (3) components:

•  Risk

•  Diagnosis and/or Management Options

•  Amount and Complexity of Data

By reviewing the links below, you can easily determine the proper MDM level of your patients. Each has been tailored to give neurologic examples.

1. Determine the Level of Risk (high, moderate, or low).

2. Determine the Level of Diagnosis and Management Options (extensive, multiple or limited).

3. Determine the Level of the Amount/Complexity of Data (extensive, moderate or limited).

Then, the level of Medical Decision Making (MDM) is determined from the table below. The level is determined by taking the lower of the two highest of the three categories.

Level of MDM Risk Diagnosis / Management Options Amount / Complexity of Data

Straightforward
 
Minimal Minimal Minimal

Low

Complexity

Low Limited Limited

Moderate

Complexity

Moderate Multiple Moderate

High

Complexity

High Extensive Extensive

(Click here for some examples)


Legal disclaimer: the above information regarding outpatient E/M codes is deemed reliable. However, physicians should always confirm the information in the 1997 CMS guidelines.