Determining Medical Decision Making Levels

You can view the health complexity of the patient from the Medical Decision - Making Elements panel based on the diagnosis and HPIs details documented in the patient encounter chart note.

Medical Decision Making (MDM) suggests the complexity level of the patient's health, based on the data points documented in the encounter chart note of the patient. You can review the MDM level and change the automatically-filled MDM elements. The suggestion of an MDM level helps you save the time spent on MDM and bill a claim with the appropriate E&M level.

For more information on the 2021 Coding Guidelines, go to NextGen Healthcare Success Community, and download the E&M Coding User Guide for NextGen® Adaptive Content Engine.

You can review the selected MDM elements in the Medical Decision - Making Elements panel on the Finalize template, and select additional MDM elements in the three MDM tables. The Medical Decision Making section in the Evaluation and Management Coding panel displays the MDM level based on the calculated levels in the Nature of Presenting Problem (Table A), Data Reviewed and Analyzed (Table B), and Patient Management (Table C) tables in the Medical Decision - Making Elements panel.

The MDM elements are categorized in Nature of Presenting Problem (Table A), Data Reviewed and Analyzed (Table B), and Patient Management (Table C) tables. Each table displays a calculated complexity level of the patient based on the automatically-filled or manually selected elements.

The MDM tables suggest the overall medical decision making level if at least two tables display calculated levels.