An outpatient coder levels an office visit using MDM. Which statement correctly describes how the three MDM elements drive the level?
Select an answer to reveal the explanation.
Short Explanation
Office MDM is a best-two-of-three contest—problems, data, and risk. You don’t need a perfect sweep of all three boxes to land the level.
Full Explanation
For office/outpatient MDM, the overall level is based on two of three elements: number and complexity of problems addressed, amount and/or complexity of data, and risk of complications and/or morbidity of patient management. A single element does not have to stand alone as the sole determinant, and history/exam bullet counting is no longer the primary office level driver under current guidelines.