Medical decision-making (MDM) is based on the complexity of establishing a diagnosis or selecting the management or treatment plan. When reporting an E/M service using the current coding guidelines as published by Current Procedural Terminology (CPT®) and the Centers for Medicare & Medicaid Services (CMS), it is the one key element that seems to be the most difficult to understand, quantify, and document. The descriptors for the level of MDM (ie, straightforward, low, moderate, and high complexity) are vague, making selection of the MDM level confusing.

Although the elements used to measure the MDM level are the same in the CPT and CMS guidelines, the CMS expanded the requirements for documentation and designed a risk table with clinical examples used only to help represent differing levels of complexity. Remember that most payers follow the requirements outlined in the CMS 1995 or 1997 Documentation Guidelines for E/M Services.

The elements of...

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