This article relates to the 1995/1997 documentation guidelines, and not to office/outpatient codes 99202–99215 in 2021.
MDM has three components.
In order to meet the level of MDM, the note must have two of the three components. These are:
- the number of diagnoses or management options
- the amount of data reviewed
- the risk of complications and/or morbidity or mortality from the presenting problem, diagnostic tests ordered or treatment options
You need two of three of these elements to select the MDM
Point system for MDM
Number of diagnosis or treatment options (new or established problems are to examiner not patient.)
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