Medical Decision Making

Physicians can use Medical Decision Making (MDM) from the Finalize template to view and select MDM elements from each of the three different MDM categories.

You can indicate that MDM is not a required component for the overall E&M level (for example, for an established patient) on the Practice Configuration template.

Under the 2021 Coding Guidelines, The Medical Decision Making automatically suggests an MDM level for a patient, based on the data points documented in the encounter chart note. The Medical Decision-Making Elements panel in the Finalize template displays the calculated level based on the pre populated MDM elements. You can review the MDM tables and change the pre populated MDM elements, as needed. The suggestion of an MDM level helps save time spent on MDM calculation and bill a claim with an appropriate E&M level.

Under the 95 or 97 Coding Guidelines, for visit types that require only two of the three possible key components to be calculated for the overall E&M Level (for example, an established patient), the MDM level must be calculated as one of the two key components. The MDM level must be used even if it is at a lower level than the history and/or physical exam. Using the MDM level as a key component supports the Centers for Medicare and Medicaid Services (CMS) guidelines of medical necessity for an E&M service.

The Medicare Carriers Manual Section 15501A states the following:

“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® Code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record . . .”

CMS and the American Medical Association (AMA) have released the 2021 Coding Guidelines, which give more weight to MDM than history or exam.

"The reason for this is simple: Patients come to a provider to have their problem (s) dealt with, not to have some degree of history or exam performed. The history and exam components are just the means providers use to gather data to arrive at some decision making related to the problem. It is the decision making component that will most often determine the true complexity of the management involved. The history and exam elements are best viewed as supporting components in terms of both work and performed and documented.” Single American Medical Association –The building Blocks of Evaluation and Management Coding. From the Ingenix, Inc. 6thed, 2003 JH Kurac, page 9.