Version 20.13
 This window map article points out some of the important aspects of the window you're working with in OP but is not intended to be instructional. To learn about topics related to using this window, see the Related Articles section at the bottom of this page. |
About Medical Decision Making Details
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounters > New or Open Note button (if unfinalized) > Coding
The Medical Decision Making Details window is read-only. It displays the breakdown that supports how each element of MDM was reached based on the documentation completed for the Encounter. While this window cannot be directly edited, it is automatically updated when changes to documentation affect the details displayed.
Important: To edit an element, close the Medical Decision Making Details window and modify the selection in the MDM coding section. Whenever modifying, include an explanation or reason in the Comments field. |
For additional information, see:
- Where and How MDM is Indicated and What OP Can and Cannot Do: Explanations of where in OP each element of MDM is indicated and what OP can and cannot do to determine the level for each element of MDM.
- Medical Decision Making Calculation Support in OP: A comprehensive view of how the level for each element of MDM is reached according to what is documented in the Encounter.
Medical Decision Making Details Map
Number | Section | Description |
1 | Problems | The Problems section displays the eight Problem Statuses that count toward MDM based and the number of each distinct status that was documented in the Encounter. |
2 | Data Review | The Data Review section lists the six actions that indicate Data Review as counted toward MDM for the Encounter. The first three actions are numerical counts and the last three actions are Yes or No indicating whether or not supporting documentation has been entered into the Encounter. |
3 | Risk of Complications | The Risk of Complications section lists the two factors that indicate Risk of Complication for the Encounter and a respective Yes or No indicating whether or not supporting documentation has been entered into the Encounter. |
| 4 | Close button | The Close button closes the Medical Decision Making Details window. If documentation is changed in the Encounter that would alter the details, relaunching this window shows the most current details. |
Version 20.12
About Medical Decision Making Details
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounters > New or Open Note button (if unfinalized) > Coding
The Medical Decision Making Details window is read-only. It displays the breakdown that supports how each element of MDM was reached based on the documentation completed for the Encounter. While this window cannot be directly edited, it is automatically updated when changes to documentation affect the details displayed.
Important: To edit an element, close the Medical Decision Making Details window and modify the selection in the MDM coding section. Whenever modifying, include an explanation or reason in the Comments field. |
For additional information, see:
- Where and How MDM is Indicated and What OP Can and Cannot Do: Explanations of where in OP each element of MDM is indicated and what OP can and cannot do to determine the level for each element of MDM.
- Medical Decision Making Calculation Support in OP: A comprehensive view of how the level for each element of MDM is reached according to what is documented in the Encounter.
Medical Decision Making Details Map
Number | Section | Description |
1 | Problems | The Problems section displays the eight Problem Statuses that count toward MDM based and the number of each distinct status that was documented in the Encounter. |
2 | Data Review | The Data Review section lists the six actions that indicate Data Review as counted toward MDM for the Encounter. Yes or No indicates whether or not supporting documentation has been entered into the Encounter. |
3 | Risk of Complications | The Risk of Complications section lists the two factors that indicate Risk of Complication for the Encounter and the respective count for each. |
| 4 | Close button | The Close button closes the Medical Decision Making Details window. If documentation is changed in the Encounter that would alter the details, relaunching this window shows the most current details. |
