What are Medical Decision Making (MDM) Guidelines in Medical Billing?

When working on Medical Billing in a medical practice, there is a lot of protocol that must be followed for the billing to be managed accurately.

One important area is the Medical Decision Making (MDM) Guidelines

Evaluation & Management (E&M) Guidelines state that each patient encounter must include a medical history, an examination, and medical decision making (MDM).

Each component requires certain types of information to be documented in the medical record. Here are the three components from the 1997 Guidelines from the CMS:


1) Medical History

– Discussion of Chief Complaint (CC)

– History of Present Illness (HPI)

– Past Family and Social History (PFSH)

– Review of Systems (ROS)


2) Physical Exam

There are Four Levels of Medical examination that can be undertaken, each with it’s own level of complexity.


3) Medical Decision Making (MDM)

– The number of diagnosis or management options

– Amount and complexity of medical data reviewed

– Risk of significant complications, morbidity, or mortality

Once these three components have been undertaken, you can then accurately report the diagnosis on the medical forms for billing.