- June 30, 2019
Medical decision making (MDM) refers to the process clinicians use to make decisions and draw conclusions from any available medical data. There are many steps involved in a complete MDM process.
- The clinician interprets available patient data, including symptoms, test results, patient self-reporting, his or her own observations and anything else professionally relevant.
- The clinician may obtain or refer to previous medical records for relevant patient history or diagnoses, previous testing, or may compare current test results to previous results.
- The clinician considers a differential diagnosis, acknowledging all possible diagnoses which could explain the given medical data.
- The clinician eliminates certain differential diagnosis possibilities, settling on a diagnosis or concluding further investigation is needed to rule out multiple possibilities.
- Instructions for each diagnosis or possible diagnosis in order to provide the best possible care given the patient’s condition and relevant medical history.
- The clinician may discuss a case with a patient’s primary care physician or consultants.
The MDM process uses a number of skills clinicians acquire through every day practice and training in order to make an informed decision to produce the optimal outcome for a patient.
Medical billing often uses MDM to justify the use of certain coding levels. More complex situations, such as unknown conditions vs. known conditions or high-risk conditions vs. low-risk conditions, correlate with higher coding levels. To aid in this coding practice, an MDM complexity score may be applied using a rubric.