This is the first of the three columns in the MDM table, and for most clinicians it is the most undercounted. It asks a simple question: how many problems did you address at this visit, and how complex are they? Get this column right and it carries a surprising number of ordinary visits to a level 4 on its own. The companion overview of medical decision making shows how this column fits with the other two.
The Word That Does All the Work: Addressed
The key word in this column is addressed. A problem is addressed when you evaluate, treat, or manage it during the encounter. Documenting that a problem exists is not the same as addressing it. Listing diabetes in the past medical history does nothing for this column. Writing that you reviewed the patient's glucose control, judged the diabetes stable on current therapy, and continued treatment is addressing it, and it counts.
This distinction is where most undercoding on the problems column happens. The work is usually being done in the room. The note simply does not say so in a way the coding system can recognize. Naming each problem you handled, and its status, is the entire task.
The Four Levels of Problem Complexity
The column scores from straightforward to high. Here is the plain-language version of each tier.
- Straightforward: one self-limited or minor problem, such as a cold, a minor laceration, or a wart.
- Low: two or more self-limited problems, or one stable chronic illness, or one acute uncomplicated illness.
- Moderate: one or more chronic illnesses with exacerbation, progression, or side effects of treatment; or two or more stable chronic illnesses; or one undiagnosed new problem with uncertain prognosis; or one acute illness with systemic symptoms.
- High: one or more chronic illnesses with severe exacerbation, progression, or side effects; or one acute or chronic illness or injury that poses a threat to life or bodily function.
The Tiers Clinicians Misjudge Most
Three categories on this column are worth understanding precisely, because they routinely get scored too low.
Stable versus exacerbated chronic illness. A stable chronic illness at goal is low complexity on its own. The same illness with an exacerbation, progression, or a treatment side effect is moderate. The difference is not the diagnosis, it is the status you document. "Type 2 diabetes, stable at goal" is low. "Type 2 diabetes with worsening control, adjusting therapy" is moderate. Say which one is true.
The new problem with an uncertain prognosis. One undiagnosed new problem whose outcome is genuinely unclear is moderate complexity by itself, even before you have a diagnosis. A new breast lump, an unexplained weight loss, or a new neurologic symptom under workup all qualify while the prognosis is uncertain. Document that the problem is new, undiagnosed, and being worked up.
The acute illness with systemic symptoms. An acute illness that is making the whole patient sick, with fever, malaise, or systemic involvement, is moderate, a step above an acute uncomplicated illness. Pneumonia with systemic symptoms is not the same as a simple upper respiratory infection, and the note should reflect the difference.
What to Write for the Problems Column
Name every problem you addressed and its status. A single clear line does it: "Managed hypertension and type 2 diabetes; both at goal on current therapy. Adjusted metformin dosing given recent weight change." That is two stable chronic illnesses, explicitly addressed, which is moderate complexity on this column. If a problem is worsening, new and undiagnosed, or systemic, say so in those words, because each of those raises the tier.
The test for any note is simple. Could a coder read your assessment and tell, without guessing, how many problems you addressed and how sick the patient is? If yes, this column will score what the visit earned. If the problems are buried in the history or left implied, it will not.
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