What feels routine to you is often high complexity
Reading your own emergency film, weighing surgery in a patient with diabetes and obesity, deciding against an intervention: these feel ordinary because you do them daily. CMS scores them as high-level decision making. The MDM table is just a map of judgment you are already exercising. The trick is recognizing it on the page.
- MDM has three elements: problems addressed, data reviewed, and risk. You need two of the three at a level to support it.
- Expertise hides complexity: the harder a decision would feel to a trainee, the more likely it is genuinely high level.
- Score what the encounter actually was, then make sure the note shows the two elements that carry it.
Medical decision making (MDM) is how most office visits get coded under the current rules. You meet or exceed two out of three columns in the MDM table, and that determines your level of service. The table has four levels: straightforward, low, moderate, and high. Those levels correspond to the E/M code you can code.
The Four MDM Levels and the Codes They Correspond To
| MDM Level | New Patient CPT | Established Patient CPT | wRVUs (New / Est. Patient) |
|---|---|---|---|
| Straightforward | 99202 | 99212 | 0.93 / 0.70 |
| Low | 99203 | 99213 | 1.60 / 1.30 |
| Moderate | 99204 | 99214 | 2.60 / 1.92 |
| High | 99205 | 99215 | 3.50 / 2.80 |
The Three Columns: What Each One Measures
The MDM table has three columns, and you need to meet or exceed two of them to support a given level. Each column asks a different question about the encounter, and each rewards a specific kind of documentation that is easy to leave on the table. Each one also has its own guide that works through the details and the common mistakes.
Column 1: Number and complexity of problems addressed
How many problems did you address, and how sick is the patient? The key word is addressed: you evaluated, treated, or managed the problem at this visit, rather than merely noting that it exists. Read the full guide to the problems column.
Column 2: Amount and complexity of data reviewed
What did you review to make your decision? This column rewards engaging with data: ordering and reviewing tests, reading outside records, talking with other clinicians, and interpreting imaging yourself. Read the full guide to the data column.
Column 3: Risk of complications from treatment
How risky is what you did or decided? This is often the easiest column to support, because the risk rubric captures complexity every clinician already understands, starting with prescription drug management. Read the full guide to the risk column.
You Need Two of Three, Not All Three
This is the rule providers most frequently misunderstand. You do not need to meet all three columns at a given level. You need to meet or exceed two of the three. This means that if your encounter has a very complex problem (column 1) and moderate-risk management (column 3), you can support a moderate-level visit even if your data review was minimal.
Conversely, if you had a straightforward problem but you reviewed extensive outside records and had a lengthy discussion with a consulting specialist, your column 2 strength may pull the overall level up.
Two Notes, Same Patient
The clearest way to see what the 2021 rules reward is one encounter documented two ways. Both notes below describe the same patient on the same day: a 62-year-old returning with worsening knee osteoarthritis, started on a prescription anti-inflammatory. The first note is long and thorough in the old style. The second is short and centered on the decision-making. Under today's rules, the second earns more.
HPI: 62-year-old returns with right knee pain, present for several years and gradually worsening. Medial, aching, about 6 out of 10. Worse with stairs and prolonged standing, better with rest and ice. No locking or giving way, no recent trauma. Partial relief with acetaminophen.
ROS: Constitutional, eyes, ear/nose/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurological, psychiatric, endocrine, hematologic, and allergic systems reviewed, negative except as noted above.
Exam: Well-appearing, no distress. Heart regular. Lungs clear. Abdomen soft. Right knee: no effusion, full range of motion, mild medial joint line tenderness, ligaments stable, no warmth. Left knee normal. Neurologic exam grossly intact.
Assessment: Knee pain.
Plan: Recommend NSAIDs and activity modification. Return as needed.
HPI: 62-year-old with known right knee osteoarthritis, returning with a three-week flare. Now limiting walking to less than two blocks and interfering with work. Acetaminophen no longer controlling it.
Exam: Right knee with small effusion, medial joint line tenderness, crepitus with motion, stable. Antalgic gait.
Assessment: Osteoarthritis of the right knee with acute exacerbation, now limiting ambulation.
Plan: Personally reviewed today's weight-bearing radiographs, showing medial joint space narrowing without acute change. Started meloxicam 15 mg daily (prescription drug management), gastrointestinal precautions reviewed. Discussed activity modification, a future corticosteroid injection, and referral for surgical evaluation if symptoms progress. Follow up in six weeks.
Same patient, same visit, the same medication started. The first note is several times longer and supports 99213, worth 1.30 wRVU. The second is a few sentences and supports 99214, worth 1.92, a difference of 0.62 wRVU on a single visit. Across a panel of similar visits, that gap is the difference between fair payment and a steady, invisible loss. The history and examination in the first note are not wrong; they simply no longer move the level. What moves it is naming the complexity of the problem, the data you reviewed, and the risk of your plan. The second note does that in three lines.
Sources and Further Reading for This Chapter
- American Medical Association, Evaluation and Management (E/M) Coding. https://www.ama-assn.org/practice-management/cpt/evaluation-and-management-em-coding
- CMS, Physician Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician