What information is vital to include when detailing MDM?

Detailing Medical Decision Making (MDM) requires a comprehensive understanding of the complexity of patient care, which includes the work involved in determining diagnoses and treatment options. This process plays a crucial role in capturing the thought process behind clinical decisions, reflecting the level of care provided and the challenges anticipated in managing the patient's condition.

Including the work involved in understanding the patient's condition allows for a clearer picture of the complexity of the case, illustrating the cognitive efforts of the clinician. This can encompass various elements such as:

• The number of diagnoses and management options considered,
• The risk of complications or morbidity associated with the patient's condition,
• The extent of data reviewed, including diagnostic tests and medical history.

These details not only provide a thorough representation of the care delivered but also support appropriate coding for the services rendered, ensuring that documentation aligns with reimbursement guidelines and reflects the true level of service provided. Thus, this information is essential for establishing both the clinical and financial aspects of patient care.