Medicare discovered that auditors were having a hard time nailing down the level of medical decision making during the medical review process in response to this problem a more objective medical decision making point system was developed by cms although not part of the official e m guidelines this mdm point system was distributed to all . Medical decision making mdm mistakes are common here are the coding and documentation mistakes hospitalists make most often along with some tips on how to avoid them listing the problem without a plan healthcare professionals are able to infer the acuity and severity of a case without . In this ed charting and coding series we have covered introduction to ed charting and coding pv card the history of present illness past medical family social history the review of systems and the physical exam at last we arrive at the crux of the chart medical decision making mdm in this final section you show your work and your thought process. In this case all three dimensions of medical decision making seven problem points five data points and high risk add up to high complexity medical decision making e m university coding tip although the risk threshold is quite high for this type of mdm the physician should remember that only two out of three elements of mdm are required to qualify for any particular level of complexity. 1995 documentation guidelines for evaluation and management services and the 1997 documentation guidelines for evaluation and management services these learn about the general principles of evaluation and management e m documentation are history examination and medical decision making visits that consist predominately
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