As noted in the cover article, “Documenting Medical Decision-making,” a proposal to use only the medical decision-making (MDM) component to determine the level of service for evaluation and management (E/M) services would likely affect the levels of service reported for E/M services when reporting based on the key component rather than time of counseling and/or coordination of care. Determining the documentation necessary to support the level of MDM starts with understanding the most common method of determining the level of MDM. Commonly, MDM is determined by use of a tool developed by the Marshfield Clinic to quantify the rather ambiguous MDM elements described in the 1995 and 1997 documentation guidelines. The Marshfield Clinic tool assigns points for the following 3 elements of MDM:

The 1995 and 1997 CMS Documentation Guidelines for Evaluation and Management Services assign ambiguous levels to each element, such as minimal, limited, multiple, and extensive to the...

You do not currently have access to this content.