Urology Coding Alert

Add up the points to determine your level of MDM complexity.

Figuring out how your urologist's assessment and plan of care documentation translates into the encounter's level of medical decision-making (MDM) complexity requires math skills. With this tool you don't have you feel overwhelmed remembering as the point values associated with each of the three MDM components.

Match up the points in each category to determine the level of each MDM requirement.

1 point = minimal, 2 points = limited, 3 points = multiple, 4 points = extensive

Choose level based on the Table of Risk:

• Minimal 
• Moderate
• Low 
• High

See the Table of Risk on page 15 of the 1995 E/M Guidelines (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf) or page 47 of the 1997 Guidelines (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf).