DeductorMD simplifies the calculation of the Medical Decision Making, MDM component of the documentation guidelines. No more guess work on the level of MDM. The app calculates it for you!
This app follows the Centers for Medicare & Medicaid Services CMS guidelines using CPT and ICD9 coding systems. Useful guide for Physicians, Mid-Levels and Medical Coders and Billers.
There are three elements within each MDM level.
1) Number of diagnoses or management options This element is based on the following:
The number and types of problems addressed during the encounter
The complexity of establishing a diagnosis
The management decisions made by the physician
Amount and/or complexity of data to be reviewed
3) The amount and/or complexity of data or other information that must be obtained, reviewed and analyzed in order to establish a diagnosis is another indicator of complexity of diagnostic or management problems. Examples of procedures that increase the difficulty of this component include:
Obtaining and reviewing old medical records and/or obtaining history from sources other than the patient
Seeking advice from others
Discussing contradictory or unexpected diagnostic test results with another physician
Reviewing the image, tracing, test or specimen ordered to supplement information.
Always remember to document the rationale for ordering diagnostic testing or other ancillary service.
2) Risk of significant complications, morbidity and/or mortality
The determination of risk is complex and not readily quantifiable. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The highest level of risk with any one presenting problem(s) (as well as associated comorbidities), diagnostic procedure(s) or management options(s) determines the overall risk.