Medical Decision Making (MDM)
Medical Decision Making
One of two methods (with time) for selecting an E/M level, based on the number and complexity of problems, the amount and complexity of data reviewed, and the risk of complications.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Coding
- Acronym for
- Medical Decision Making
- Primary sources
- 2
- Workspace handoff
- revenue audit →
Where this comes up
Coders meet this term inside the chart at the moment of code selection — picking the E/M level, attaching the right modifier, defending the procedure code against an NCCI edit, or answering an auditor who pulled the encounter for a payer-initiated review.
Full definition
What it is in practice
The 2021/2023 AMA E/M revisions use a three-element MDM grid (problems, data, risk). The level is set by the two highest of three. CMS accepts this method for all sites of service.
How it shows up in your practice
Document the problems addressed and the data reviewed (labs, imaging, independent historian) explicitly. Risk language — prescription drug management, possible surgery — is what frequently lifts a visit from a 3 to a 4.
Sources
- CMS — Evaluation and Management (E/M) Services Guidehttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
- AMA — 2021 / 2023 E/M Documentation Guidelineshttps://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
Run an MDM audit in Revenue Audit
Open revenue audit →Related terms
- CodingE/M CodingEvaluation and Management codes (99202-99499) used to bill office, hospital, and other professional visits.
- CodingTime-Based BillingMethod for selecting an E/M level using the total time spent on the date of the encounter.
- Coding99214 vs 99215The two most common established-patient office E/M levels; 99214 represents moderate complexity and 99215 high complexity.
- DocumentationDocumentation CloningThe practice of copying prior or template-generated documentation into a new encounter note without updating it for the current visit.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- Glossary99214 vs 99215The two most common established-patient office E/M levels; 99214 represents moderate complexity and 99215 high complexity.
- GlossaryE/M CodingEvaluation and Management codes (99202-99499) used to bill office, hospital, and other professional visits.
- GlossaryTime-Based BillingMethod for selecting an E/M level using the total time spent on the date of the encounter.
- GlossaryDocumentation CloningThe practice of copying prior or template-generated documentation into a new encounter note without updating it for the current visit.
- Billing99214 vs 99215: When to Bill Each CodeLearn the difference between 99214 and 99215: when each applies, what documentation you need, and the $40/visit revenue impact.
- GlossaryMedical Decision Making Risk ElementThe third axis of MDM-based E/M leveling, reflecting the risk of complications, morbidity, or mortality of patient management.
- GlossaryProlonged ServicesAdd-on codes used when a visit exceeds the time thresholds of the highest base E/M code.
- RegulationMLN: 2021 E/M Office Visit Coding RevisionsReference to the 2021 CPT E/M office visit (99202-99215) code revisions: history and exam no longer used for code selection; medical decision making or time controls.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.