Clinical Documentation Improvement Series 21. Evaluation and Management Documentation 6. Data Points of the Medical Decision Making

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Problem Points of the Medical Decision Making

The data points of the Medical Decision Making are evaluated by a scoring system:

• 1 point for reviewing or ordering clinical tests.
• 1 point for reviewing or ordering radiological tests.
• 1 point for reviewing or ordering medical tests.
• 1 point for making the decision to obtain old medical records.
• 2 points for the independent review of image, specimen or tracing.
• 2 points for the summarized review of the medical record

Bibliography

Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. "Evaluation and Management Services." Accessed April 14, 2020. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Marco A. Ramos MD, CCDS

In order to quote from this article in bibliography, Chicago style, please use the following:

Ramos, Marco. “Clinical Documentation Improvement Series 21. Evaluation and Management Documentation 6. Data Points of the Medical Decision Making”. SMO Blog (blog). April 13, 2020. https://hive.blog/hive-163521/@secondmedicalop/clinical-documentation-improvement-series-21-evaluation-and-management-documetation-6-data-points-of-the-medical-decision-making

Links to the Previous Posts in this Evaluation and Management Series

- Clinical Documentation Improvement Series 16. Evaluation and Management Documentation 1. Components of the History of Present Illness

- Clinical Documentation Improvement Series 17. Evaluation and Management Documentation 2. Individual Systems of the Review of Systems

- Clinical Documentation Improvement Series 18. Evaluation and Management Documentation 3. Areas of the Past, Family and Social History

- Clinical Documentation Improvement Series 19. Evaluation and Management Documentation 4. Organ Systems of the Physical Exam

- Clinical Documentation Improvement Series 20. Evaluation and Management Documentation 5. Problem Points of the Medical Decision Making

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