Complexity of problems addressed: Communicate to clear confusion in MDM table

Why This Topic Matters

Accurate interpretation of the problems-addressed element affects E/M leveling, documentation review, and the communication process between coders and clinicians. The article helps readers understand why provider clarity matters when a diagnosis appears in the record but may not have been actively addressed during the encounter.

Article Sections

1. Coding

   Introduces the training focus and the relevance of recent guidance for office/outpatient E/M services. Frames the article around documentation, coding, and billing collaboration.

2. Open the lines of communication

   Discusses the need for coder-clinician communication when evaluating the problems-addressed element. Summarizes guidance from AMA and CPT Assistant on clarifying provider intent and problem status.

3. A new maxim emerges

   Reviews guidance on when documented diagnoses contribute to E/M leveling and when they do not. Emphasizes the relationship between documentation and whether a problem was addressed during the encounter.

4. Use caution when adding problems

   Addresses how multiple problems may affect the level for this MDM element and cautions against automatic counting. Summarizes contractor and CPT Assistant guidance on selecting a level based on the addressed problems.

5. Treatment goals help set the score

   Focuses on stability, treatment goals, and how provider documentation supports assessing problem status. Includes contractor guidance on chronic conditions, expected duration, and patient progress toward goal.