EM Coding Alert

Translate your provider’s documentation into an MDM level.

Even if math is not your strongest skill, calculating how your providers assessment and plan of care documentation translates into the encounter’s medical decision-making (MDM) level of complexity doesn’t have to ruin your day. With this tool you don’t have you feel overwhelmed remembering as the point values associated with each of the three MDM components.

Match up the points in each category to determine the level of each MDM requirement.

1 point = minimal, 2 points = limited, 3 points = multiple, 4 points = extensive

Risk of Significant Complications:

Choose level based on the Table of Risk:

• Minimal 
• Moderate
• Low 
• High

See the Table of Risk on page 15 of the 1995 E/M Guidelines (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf) or page 47 of the 1997 Guidelines (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf).