This article continues a series intended to serve 2 purposes.
The amount and/or complexity of data to be reviewed and analyzed at an encounter is 1 of 3 elements of MDM when using the current guidelines for E/M services to select codes for office E/M services. At least 2 of the following 3 elements must be met at the same level (straightforward, low, moderate, or high) to support the level of MDM:
Future articles will focus on selecting a level of MDM based on any 2 of 3 elements. This article is focused only on what constitutes data to be reviewed and analyzed.
The Current Procedural Terminology (CPT®) E/M guidelines, while detailed, provide a foundation for understanding how to correctly use a simple table to determine E/M services at levels 2 through 5. Understanding what counts toward each of the 3 elements of MDM provides the basis...