Evaluation & Management Part 3: Medical Decision Making

Now it is time to wrap up the evaluation and management (E/M) series with the third and final part: the medical decision-making component.  This too was a topic covered at the Karen Zupko & Associates conference on General Surgery coding in Chicago, IL, and has been identified as one of the more difficult components to code because of its complexity.  The Centers for Medicare and Medicaid Services (CMS), does, however, provide detailed guidelines for documenting and determining the appropriate level of medical decision making.  Per CMS (2017), “medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option” (p. 13).  Additionally, per CMS (2017), the medical decision-making component is determined by three major factors:

  1. The number of potential diagnoses and/or various management options
  2. The amount and complexity of data, such as diagnostics and medical records, that are reviewed or must be obtained
  3. The level of risk associated with the patient’s condition.

What makes coding medical decision making so difficult is determining exactly which level of complexity the E/M represents.  Per CMS (2017), there are four levels of medical decision-making complexity.  These are ordered from level of least complexity to level of highest complexity:

  • Straightforward:  Minimal or no amount and complexity of data reviewed, minimal diagnoses or management options, and a minimal level of risk
  • Low Complexity:  Limited amount of complexity of data reviewed, limited diagnoses and management options, and a low level of risk
  • Moderate Complexity:  Moderate amount and complexity of data reviewed, multiple number of diagnoses or management options, and moderate level of risk
  • High Complexity:  Extensive amount and complexity of data reviewed, extensive number of diagnoses or management options, and a high level of risk.

Even with these definitions and guidelines put forth by CMS, there still remains some confusion as to how to accurately represent this component of the E/M.  The language may seem clear, but as was discussed at the conference and from my personal experience in coding, there is still a gray area in determining just how complex a provider’s medical decision-making component really is.  CMS does provide a useful table, which indicates the various levels of E/M medical decision-making complexity and examples to illustrate what each might look like in actual practice.  As was mentioned in parts 1 and 2, documentation is key and must reflect all medical decision-making aspects performed during the E/M.  This will help medical billers, coders, and providers alike in determining which level of complexity is most appropriate, and ultimately will lead to more accurate and appropriate E/M coding.

MedPro Services continuously seeks out educational opportunities, such as the Karen Zupko & Associates conference that was featured prominently in this three-part series.  Our team is informed and knowledgeable on current and future CMS guidelines and initiatives.  For more information on how we can help your practice, please send us a message and we will be more than happy to assist.


Centers for Medicare & Medicaid Services. (August, 2017). Evaluation and management services.  Medicare Learning Network. 

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