CPT® Coding: Medical Decision Making

This presentation discusses medical decision making, a component of CPT’s evaluation and management (E/M) codes. The video discusses the definitions of the medical decision making (MDM), the 3 components of MDM and compares these components.

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MDM includes these three levels: straightforward, low complexity, moderate complexity, and high complexity.
The correct level is determined by these three components:
Number and complexity of problems addressed
Amount and/or complexity of data to be reviewed and analyzed
The risk of complications and/or morbidity and or mortality of patient management.
Amount and/or complexity of data includes three categories: Category 1 is review and ordering of tests. Category 2 includes interpretation of tests. Category 3 includes discussion of tests with another provider.
The video also defines terms such as Test, Unique Test, Minimal problem; self-limited or minor problem; chronic illness; stable chronic illness; chronic illness with exacerbation, progression or side effects of treatment; acute illness, uncomplicated; acute illness, complicated; acute illness with systemic symptoms; acute or chronic illness or injury that poses a threat to life or bodily function; and undiagnosed new problem with uncertain prognosis.

This video is excerpted from the book Evaluation and Management Coding Made Easy, available on Amazon.

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Contents of this video
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00:00 - Introduction
1:23 - What is MDM?
3:17 - Levels of MDM
6:30 - Problems addressed
16:27 - Data Reviewed
24:24 - Risk
31:00 - Putting it all together
35:03 - Notes to make in CPT book