Medical Decision Making | Documentation Guidelines for E/M Services (2024)

The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023.

This article does not apply to services performed after 1-1-2023.

Medicaldecision making (MDM) is one of the three key components of evaluation and management services. (Make sure you readabout the other twocomponentshistoryandexamas well.)

In order to meet the level of MDM, the note must have two of the three components. These are:

Number of diagnosis or treatment options (new or established problems are to examiner not patient.)

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