One method to help you calculate the correct E/M service level and code is to write the letters H, E, M (H = History, E = Exam, M = MDM), and — as you read the E/M questions in the exam — mark the level of each key component.
How is MDM level calculated?
- The number of diagnoses and/or management options that the provider must consider;
- The amount and/or complexity of medical records, diagnostic tests, and/or other data the provider must get, review, and analyze; and.
How is complexity of medical decision making determined?
Physicians must stratify the MDM into one of the above levels of complexity based on: The nature and number of clinical problems. The amount and complexity of the data reviewed by the physician. The risk of morbidity and mortality to the patient.
