Medical Decision-making (MDM) level is set by two of three elements: Problems, Data, and Risk. In behavioral health, Data is usually Minimal or Low — so Problems and Risk are typically the two that decide your level. This shortcut is built on those two. Your note has to make both visible.
Documentation 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 when you change nothing, document that you re-evaluated and why you continued.
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; the rest of the note shows how you thought about and managed it.
Example of MDM carried outside the Assessment:
HPI: Reports sleep improved to 6 hours, still waking twice. ROS: Denies akathisia. Plan: Continue current dose; recheck in 6 weeks, sooner if sleep regresses.
Step 3: Determine the level using problems and risk
Data is usually Minimal or Low — so Problems and Risk are the two that decide your level. You need both a Problems finding and a Risk finding at a level to bill it.
| MDM level | Clinical picture / managment | Risk | Documentation should show... |
| Low (99203 / 99213) | One stable chronic condition at treatment goal | Routine management, no medication change | Why the plan remains appropriate and stable |
| Moderate (99204 / 99214) | One chronic condition with mild/moderate exacerbation, partial response or side effects of treatment two stable chronic conditions (stable = at treatment goal) |
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| High (99205 / 99215) | Severe exacerbation, or significant functional or safety risk | High-risk medication requiring toxicity monitoring (≤90 days), or consideration of inpatient admission |
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Step 4: When psychotherapy is added
If adding codes 90833, 90836, or 90838, level your E/M by MDM (table in step 3), not time.
Document time twice: total session time, and psychotherapy-only time.
Below all E/M content document the therapy itself:
- Symptoms and behaviors addressed with therapy
- Interventions used, and how they were used
- Patient response to interventions
- Goals specific to therapy
- Progress toward therapy goals
Keep medical management and psychotherapy in visibly separate sections. Unclear separation of E/M and therapy time is a common audit flag.