It is no secret that selecting a Current Procedural Terminology (CPT®) code for an evaluation and management (E/M) service is complex even when the reason for the service is not so complex. Perhaps the most misunderstood component of the E/M service is medical decision-making (MDM). For some conditions, the level of MDM may be readily apparent (eg, life-threatening injury with decision for major surgery), but for others, the criteria for determining the level of MDM may be less clear. To illustrate how MDM level is determined, this article will use coding scenarios with diagnoses of acute otitis media, upper respiratory infection (URI), sinusitis, and pharyngitis and apply E/M audit tool criteria for MDM (see “Medical Decision-Making: A Refresher” on page 1 for criteria). Note that only the MDM will be reviewed for each case study.

The overall level of E/M is determined through a combination of key...

You do not currently have access to this content.