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The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023.

This article does not apply to services performed after 1-1-2023.

Definition

Medical decision making (MDM) is one of the three key components of evaluation and management services. (Make sure you read about the other two components history and exam as well.)

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.)