Accurate MDM coding requires transparent documentation that shows how decisions were made. Clear reasoning protects both providers and patients.
Please note: This shortcut assumes the "Data" element is typically Minimal or Low.
Shortcut quick reference
- Stable treatment: Describe why it's appropriate to continue.
- Treatment changes: Document what changed and why.
- Significant risk: Describe how you managed or mitigated it.
Step 1: Document your decision-making process
Even if no changes are made, document the re-evaluation and reasoning.
Patient presentation → Clinical reasoning → Documented decision
Each note should clearly show why the billed service level is appropriate, focusing on the provider's clinical reasoning.
Example: "Patient remains stable on current medication. Reviewed potential side effects and confirmed continuation of same dose."
Step 2: Show MDM throughout the note
MDM should be visible throughout your note, not just in the Assessment section. The assessment names the problem, and the rest of the note shows how you thought about and managed it.
Step 3: Determine the level using problems and risk
| MDM level | Clinical picture / managment | Documentation should show... |
| Low (99213) | Stable chronic condition; routine management, no med changes | Why the plan remains appropriate and stable |
| Moderate (99214) | Chronic condition with mild to moderate exacerbation, partial response, or side effects; and Start/Stop/Refill Rx | What changed, why it changed, and how you’re managing or monitoring the outcome |
| High (99215) | Severe exacerbation or significant functional/safety risk; and high-risk medication (toxicity monitoring ≤90 days) or consideration of inpatient admission | Explicit rationale for risk, factors contributing to risk, and interventions or monitoring to ensure safety |
Step 4: When psychotherapy is added
If adding codes 90833, 90836, or 90838, level your E/M by MDM, not time.
- Clearly separate medical management from psychotherapy documentation
- Documentation must show:
- Time: document both total session and therapy-only time
- Audits may flag unclear separation of E/M and therapy time.
- Symptoms/behaviors addressed with therapy
- Interventions used and how they were used
- Patient response to interventions
- Goals specific to therapy
- Progress towards therapy goals
- Time: document both total session and therapy-only time