What your note needs to support a 99214 under the MDM rules

Since January 1, 2021, the level of an office or outpatient visit has been set by one of two things: the level of medical decision making (MDM) or the total time you spent on the date of the encounter. The history and exam still need to be medically appropriate, but CMS states that their extent isn't an element in selecting the level.

That moves the weight of the note to the assessment and plan. When I audit a chart, that's where I start, and it's where most of the level 4 visits I downgrade fall short.

Charted suggests ICD-10 codes only. It doesn't pick a visit level, and that decision should stay with you and your coders. What follows is what the note itself has to show.

Two of three elements

MDM has three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity or mortality from patient management. The level is the highest one met by at least two of the three. For a 99214 (established patient) or a 99204 (new patient), two of the three have to reach moderate.

• Problems, moderate: one or more chronic illnesses with exacerbation, progression or side effects of treatment; two or more stable chronic illnesses; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; or one acute complicated injury.

• Data, moderate: at least one of three categories. Category 1 is any combination of three items from this list: review of prior external notes from each unique source, review of the result of each unique test, ordering of each unique test, and assessment requiring an independent historian. Category 2 is independent interpretation of a test performed by another physician or qualified health care professional. Category 3 is discussion of management or test interpretation with an external physician, other qualified professional or appropriate source.

• Risk, moderate: for example, prescription drug management, a decision about minor surgery with identified patient or procedure risk factors, or diagnosis or treatment significantly limited by social determinants of health.

Problems: say whether it's at goal

Stability is judged against the patient's treatment goal. A patient whose blood pressure or A1C is not at goal has a chronic illness that is not stable for coding purposes.

So the assessment should say it in words: "Hypertension, above goal" or "Type 2 diabetes, A1C 8.4%, goal under 7%." A bare diagnosis followed by "continue current plan" reads as stable to a reviewer.

Count only the problems you addressed at this visit. A condition managed solely by another clinician doesn't count toward this element, and neither does one you didn't address. The problems in the history should match the problems in the assessment and plan, so a reviewer can follow each one through the note.

Data: name what you looked at

"Labs reviewed" doesn't tell a reviewer which tests or how many. Write the test and the result: "BMP from June 2 reviewed, potassium 4.1, creatinine 0.9." Each unique test counts once, and a panel such as a basic metabolic panel is a single test. Name the source of outside records, as in "cardiology note from May 20 reviewed," and say when a parent or caregiver gave the history.

Risk: write the decision

The most familiar moderate-risk item is prescription drug management, so the plan should name the drug and the decision. "Increase lisinopril from 10 mg to 20 mg daily" shows it. "Continue current medications" leaves a reviewer guessing which drugs you managed. If social circumstances shaped the plan, such as a patient who can't afford the first-choice drug, write that down as well.

A worked example

Take a hypertension follow-up. The patient reports taking every dose. Home readings run around 140/90 and the clinic reading is 146/92. You increase lisinopril from 10 mg to 20 mg daily and order a basic metabolic panel in two weeks.

• Problems: one chronic illness not at goal, which is moderate.

• Data: one test ordered. Limited data needs two of the Category 1 items, or an assessment that required an independent historian, so this falls below it.

• Risk: prescription drug management, which is moderate.

Problems and risk both reach moderate, so MDM is moderate and the visit supports a 99214. The note still has to carry it. If the assessment says only "Hypertension" and the plan says "Adjust meds," a reviewer has to guess at both.

Time instead of MDM

When most of a visit is counseling, total time may support the level better than MDM. Count only the time you personally spent on that patient on the date of the visit, documentation included. A 99214 needs at least 30 minutes of that time, and a 99204 at least 45. Staff time and time spent the next day don't count. CMS asks you to document either the total time or the start and stop times.

Questions we get

Does a longer note support a higher level?

No. CMS tells practitioners not to use the volume of documentation to decide the level of service. A short note that states each problem and decision clearly supports more than a long one that doesn't.

Do I still need a full review of systems?

Document a history and exam that are medically appropriate for the visit. Under the current rules, their extent doesn't change the level.