The second element of MDM: amount and/or complexity of data

There are three elements in medical decision-making and this article describes the second, arguably, the most complex of the three elements
When selecting a level of service based on medical decision-making two of the three elements are required
CPT^® has developed definitions for many of the components in the MDM chart. This article describes the definitions and rules related to data

This post includes:

Quick reference sheet Credit for tests in the data element
A brief video summary with downloadable slides
Definitions related to data in the new MDM chart for E/M services
Selecting the level of data using the new MDM chart for E/M services
Although the video is labeled “2021” these rules are expanded to all E/M services for 2023

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Relevant Search Terms: E/M changes 2021, CPT and CMS amend rules

Last revised January 10, 2023 - Betsy Nicoletti
Tags: E/M medical decision making

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In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.