E/M coding by medical decision making: how the levels work

Two ways to choose the level

For office and most other E/M services, the level is selected on either the level of MDM or the total time the practitioner spent on the date of the encounter, whichever better supports the service. History and examination are still documented as medically appropriate but no longer set the level.

The three elements of MDM

MDM is judged on three elements:

• The number and complexity of problems addressed at the encounter.
• The amount and/or complexity of data to be reviewed and analyzed.
• The risk of complications, morbidity or mortality of patient management.

The two-of-three rule

To reach a given MDM level (straightforward, low, moderate or high), two of the three elements must meet or exceed that level. A visit with high risk but minimal problems and limited data does not reach high MDM. Working through each element separately and then applying the rule is the reliable method on the exam.

Common traps

• Problems count only if they are addressed at this encounter, not merely listed in the history.
• New versus established patient depends on whether the patient received professional services from the same physician, or one of the same specialty in the same group, within the past three years.
• Time-based coding uses total time on the date of the encounter, including non-face-to-face work that day, and must be documented.