Evaluation, Management, Coding, and Documentation: What All Psychiatrists In Clinical Practice Need to Know-MDM Table

MDM Table

Pdf Summary

This document provides a table outlining the elements of Medical Decision Making (MDM) for E/M code selection, specifically focusing on psychiatric examples. It emphasizes that E/M code selection can be done based on MDM or time, but not both. The level of MDM selected is determined by the nature of the presenting problem on the date of the encounter. When billing E/M with a psychotherapy service, the E/M must be selected based on MDM.<br /><br />To qualify for a particular level of MDM, at least 2 out of the 3 elements for that level must be met or exceeded. The elements include the number and complexity of problems, the amount and/or complexity of data reviewed and analyzed, and the risk of complications and/or morbidity/mortality of patient management.<br /><br />The table provides examples of MDM levels for different settings and CPT codes, along with time ranges. It categorizes the level of MDM as straightforward, low, moderate, or high, and provides corresponding examples for each level. The examples given include visit for bereavement following the death of a spouse as a straightforward case, follow-up visit for major depression as a low-risk case, exacerbation of chronic illnesses as a moderate-risk case, and chronic illnesses with severe exacerbation or acute or chronic illnesses posing a threat to life as high-risk cases.<br /><br />The table also includes categories for tests, documents, or independent historians, as well as independent interpretation of tests performed by another physician and discussion of management or test interpretation with external physicians or other qualified healthcare providers. These categories contribute to the combination of elements required for each level of MDM.<br /><br />In summary, this document provides a comprehensive table with examples to help healthcare professionals determine the level of MDM for E/M code selection in psychiatric cases based on the nature of the presenting problem and the complexity of data and risk involved.

Keywords

Medical Decision Making

E/M code selection

psychiatric examples

nature of presenting problem

MDM or time

psychotherapy service

MDM levels

CPT codes

risk of complications

qualified healthcare providers