About Medical Decision Making (MDM)

In Medical Note, the Medical Decision Making (MDM) section is an important component of clinical documentation, guiding you in determining the level of complexity of medical care provided during a patient encounter. Based on the latest Current Procedural Terminology (CPT) code guidelines outlined by the American Medical Association (AMA), the MDM section uses a structured framework to assess the complexity of the patient's condition and the extent of management required. Based on the problems addressed during the visit and the associated complexities of these conditions, Medical Note recommends a document-based CPT code that reflects the level of care provided.

In the MDM section, active diagnoses are pulled in automatically to help streamline the documentation process. Also, you have the flexibility to select from the patient's active problem list if specific conditions were addressed during the encounter, ensuring accurate and comprehensive reporting of the medical decision-making process.