Along with history and physical examination, medical decision making is 1 of the 3 major criteria used when determining the level of Evaluation and Management (E/M) code to use for services furnished. It also is the most difficult to document, frequently being cited as unsupported in audits.

Remember that 4 types of medical decision making are recognized when coding an E/M service: straightforward, low complexity, moderate complexity, and high complexity. Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by

Medical decision making is represented in Table 1.

The American Academy of Pediatrics Committee on Coding and Nomenclature recently reviewed, revised, and amplified the medical decision making outlines (Tables 2 and 3), which show the progression of elements required for each level of medical decision making. The outlines now are more consistent with the thinking of pediatricians and...

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