Increasingly, physicians and health plans are moving toward the use of medical decision-making (MDM) as the key component for selecting a level of evaluation and management (E/M) services. The importance of recognizing how documentation supports or does not support a level of MDM must be a priority for all pediatricians who provide E/M services. In this article, you will be asked to recognize the MDM elements in 2 scenarios. A brief review of these elements follows to help with the scenarios.

Current Procedural Terminology (CPT®), the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services, and the commonly used Marshfield Clinic audit tool offer instruction for selecting the level of complexity of MDM. For ease of use and in consideration of space within this newsletter, here are the CPT guidelines with addition of examples from the Marshfield Clinic tool.

The elements of MDM are

The complexity of...

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