From a patient perspective, a physician’s medical diagnostic expertise, or medical decision-making (MDM), is the service that contributes the most value to a visit’s eventual outcome. This is true regardless of the extent of history or examination required to provide such expertise. Moreover, as electronic health records easily allow for extensive and comprehensive documentation of the history and examination, and concern grows that at times this results in more than necessary data being included in the documentation, MDM is being given greater weight by many payers. The result may take the form of policies that require MDM as one of the key components supporting an established patient evaluation and management (E/M) service.

Medical decision-making is selected based on a combination of elements, including the number of diagnosis and management options, amount or complexity of data, and risk to the patient. Each of these elements has its own level of complexity....

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