I am looking for some guidance, I seem to be getting conflicting info and I just can’t seem to wrap my head around determining the level of MDM….Here’s what I have- provider is pain management and treats patient’s consistently for the same issues..

In my example this is what I have – Hx is Detailed, Ex is Detailed…clear and cut…But the MDM I think I am overthinking and I need some assistance or tutoring…In the assessment I usually have 4 dx codes, sometimes more…For this example I have dx codes listed G89.4 (Chronic Pain Syndrome), M54.12, (Radiculopathy cervical region) M25.511 (rt shoulder pain), and M25.512 (lt shoulder pain)—-Provider states Reviewed UDT, MRI, and Refilled Rx Opioids

Do I count- 4 points dx under the dx/management options because he has 4 dx listed (High)…….2 points for Data (UDT and MRI review) LOW, and under Risk- MODERATE for Rx refill and he states in the Risk section 1 chronic condition with mild exac- this leads me to believe it’s the Chronic Pain syndrome since he is managing the patients pain

I am thinking Moderate Overall—-High on dx/managment, Low on Data, and Moderate on Risk….Am I doing this right…..the dx are all established codes…no indication of worsening,