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Understanding the MDM Component When selecting by MDM, documentation must demonstrate straightforward complexity, including: Evaluation of a single, stable condition or self-limited problem Minimal or low-risk management decisions Review of limited data (e.g., one lab or prescription refill) No immediate threat to patient safety or significant risk of complications When to Use CPT 98012: Common Scenarios and Use Cases CPT 98012 is appropriate when a physician, nurse practitioner (NP), or physician assistant (PA) provides a synchronous audio-only evaluation and management (E/M) visit with an established patient that involves straightforward medical decision making (MDM) or more than 10 minutes of total provider time on the same day
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