A patient encounter requires the provider to make medical decisions also known as medical decision making (MDM). A patient's medical record is required to demonstrate and document those medical decisions. The documentation must stratify the medical decisions based on complexity. A coder based on documentation will "code" the level of complexity based on the following:
Module Outcomes:
List the 11 Organ Systems
List the 7 or 10 Body Areas
List the 9 Methods of Exam
Describe how "The Exam" is included in the medical documentation.