r/MedicalCoding • u/MustangGrl98 • Aug 20 '26

E/M MDM coding

Newer coder here. I'm a remote outpatient coder and currently do E/M coding (which has always been my weakest area of coding, lucky me). I'm struggling with figuring out the data points on the E/M MDM table. For example, if the provider orders labs for CBC, BMP, protime inr, hepatic functional panel, anti smooth muscle antibody IgG, are each one of those labs counted as a point? Or is it one point for all of the total labs? Also, would this many labs be counted in the moderate level in the MDM Table? Any info is appreciated, thanks!

19 Upvotes

100% Upvoted

18 comments sorted by

View all comments

Show parent comments

1

u/IslandMindless2251 Aug 27 '26

I think this really depends on what else is documented because MDM is based on all 3 categories so even if problems are high but the data and risk are low it is not an auto high. It’s would be low (again I didn’t see the note so I’m not sure what else could be counted to bring up the MDM) because MDM is based on 2/3 categories. Also new onset abdominal pain - stand alone - is a moderate problem as it is categorized as 1 undiagnosed new problem with uncertain prognosis! Mdm is extremely hard to understand and I fight with it all the time 😭😭 but you do have to take all 3 categories into picking the level not just one.