Decision making is probably the most important factor in coding. First, it is becoming common practice that the decision-making must meet the criteria for the level that you are charging. Even if the history and exam are 99214, most insurance companies won’t pay for a level 4 if the decision making is only level 3. The notion is that the detailed exam wasn’t completely necessary if the problem was low-risk. Also, on all new patients, you must have a decision making in line with the charge you have selected.
Decision making consists of 3 parts:
1) diagnoses
2) data
3) risk
In order to qualify for an appropriate level of decision-making, at least two out of the above three must meet the criteria. For example, if you have diagnoses consistent with level 5, risk consistent with level 4, and data at a level 3, then it would be appropriate to call this level 4 decision making (two out of the three were at a level 4 or above).
Medical Coding and Billing For Residents 