Hint: The \"if this, then that\" notes are key when determining level of risk.
Selecting the appropriate level of service for an evaluation and management encounter, such as an office visit, leads most coders to determine that the medical decision making (MDM) complexity is the most complicated and difficult piece of the puzzle. But if calculating has you scratching your head, you aren't alone.
To determine the level of MDM, you should assign points to each of the three MDM components that your physician performs. The number of points in each category determines the final MDM level. There are three elements that contribute to the complexity of your doctor's medical decision making. \"The elements are diagnoses/management options, complexity of data reviewed/ordered, and the table of risk,\" says Suzan Berman, CPC, CEMC, CEDC, Senior Director of Physician Services at Healthcare Revenue Assurance Associates based out of Plantation, Florida.
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