Medical Decision-Making in Evaluation and Management Coding: Practical Applications and Key Clarifications

Recent updates to evaluation and management coding emphasize medical decision-making (MDM) as the primary determinant of visit level, though clinicians still face challenges in application. Medical decision-making is established by meeting criteria in 2 of 3 domains: problem complexity, data, and risk. In this article, key clarifications are discussed, including inadequately controlled conditions as moderate complexity; distinction between prescription drug management and simple refills; inclusion of relevant social determinants of health; and classification of independent test interpretation under data. Additional nuances in procedural decision-making and common clinical scenarios also are reviewed to support accurate coding and documentation.