MDM: problems addressed

Where you are

You have selected the appropriate E/M family and patient or visit status. Now begin medical decision making, or MDM. Keep its three elements separate: problems addressed, data and management risk. This lesson concentrates on the first element. The next lesson combines all three.

Do not begin by counting every diagnosis in the electronic record. Read what the reporting clinician actually evaluated or treated during this encounter. Your abstraction should describe the work in the note, not everything the patient has ever experienced.

Addressed is an action, not a list position

AMA's current FAQ explains that a problem is addressed when the reporting clinician evaluates or treats it at the encounter. The clinician, rather than the coder, determines whether the condition is stable or worsening. [em-faq-ama, Number and complexity of problems addressed]

Use those two checks together. A condition may appear in a copied history without being addressed today. A short assessment and plan may show meaningful work even when the note is not lengthy. Look for the current evaluation, decision or treatment rather than relying on where a diagnosis appears on the screen.

Make a table in your notebook with four columns: problem, current evidence, action taken and unresolved question. You are not reproducing the MDM scoring table. You are organizing the record so that you can apply the authorized table accurately.

Worked problem inventory

Original fictional office record, September 10, 2026: the patient returns for follow-up of hypertension. The clinician reviews home readings and symptoms, documents that the condition is at the agreed treatment goal, and continues the current management plan. The history also lists a remote healed ankle injury and seasonal allergies. Neither is evaluated or managed in this encounter.

Your current problem inventory contains the hypertension work. It does not add the healed injury and allergies merely because they are visible in the history. Record the clinician's stated assessment and action. Then use your current book to classify the problem element; do not yet decide the entire MDM level.

If the note also contained an active evaluation and management plan for the allergies, you would revisit the inventory. The issue is not whether allergies are “important enough” in your personal judgment. It is whether the record supports that they were addressed and how the applicable definitions classify the work.

Stability needs a clinical assessment

A single measurement is not a complete statement about disease status. A coder should not label a problem stable simply because a value resembles last month's value, or label it worsening solely because it differs. Preserve the clinician's assessment and seek clarification when the documentation does not establish what you need. [em-faq-ama, Number and complexity of problems addressed]

Original fictional comparison: both records concern the same chronic condition. Record A includes the clinician's assessment that the condition is controlled at the patient's goal and an ongoing plan. Record B describes worsening symptoms, treatment response and a revised plan, but leaves the severity of the change unclear. The disease name alone does not make these encounters equivalent.

In Record B, do not silently insert a severe exacerbation into the note. Write the unresolved question in the fourth column. This keeps a plausible interpretation from becoming a fabricated clinical fact.

Chronic does not mean unchanged

Use the full current definition of chronic illness and its status categories in your authorized book. A long-standing condition can be controlled, worsening or associated with treatment effects. Its duration and its present condition answer different questions.

Consider a fictional patient whose longstanding disease is reassessed after new symptoms. The useful abstraction includes the symptoms, the clinician's interpretation and the resulting plan. “Chronic problem” alone discards the information needed to distinguish today's work.

Now consider a note that repeats the same diagnosis at several points: history, assessment and medication discussion. Those are not automatically three different problems. Build your inventory around the clinical problems addressed, then use the book's instructions to determine their treatment in the problem element.

Acute problems need more than an adjective

An acute complaint may be uncomplicated, involve systemic effects, require further assessment or have another qualifying circumstance under the current definitions. Do not choose a category simply because the patient uses words such as “terrible” or “sudden.” Those words are useful history, but they do not replace the clinician's assessment.

Original fictional record: a patient presents with a new symptom. The clinician documents examination findings, an assessment, a diagnostic plan and follow-up precautions. Before classification, identify whether the note actually establishes the applicable nature and complexity of the problem. A symptom that is new to the patient does not automatically satisfy every definition containing the word “new.”

Keep the exact distinction in your book beside the worksheet. The purpose of this exercise is to notice which facts the definition requires, not to memorize a shortcut that every first-time symptom has the same complexity.

Do not convert diagnosis-code detail into MDM automatically

Diagnosis coding and E/M selection use the same clinical record for different purposes. A detailed diagnosis code can identify a site, manifestation or other feature. That detail does not independently calculate the MDM level.

For example, your diagnosis abstraction may need a precise anatomical site. Your E/M worksheet still needs the problems addressed, data and management decisions. Conversely, uncertainty about a final disease diagnosis does not mean no evaluation or management occurred. Keep both tasks grounded in the documented encounter.

When reviewing an answer, ask whether you have explained the problem element or merely restated the diagnosis. “The patient has condition X” is often only the starting point. “The clinician evaluated X, documented its current status and made this plan” gives you a usable record summary.

A disciplined pause before assigning the level

At this point, you should have an inventory of supported problems and the facts needed to compare each with the current definitions. You have not yet finished MDM. A strong problem element cannot stand in for the other elements, which you will examine next.

Mark your worksheet “problem element only.” This simple label prevents a common review error: carrying a preliminary conclusion forward as if the whole encounter had already been scored.

Book drill

Open the current E/M guidance in your authorized book. Compare the definitions for the chronic and acute problem categories used in its MDM table. For each worked record, underline the fact that supports your choice and circle anything missing. Write your own short explanation; keep the complete copyrighted table in your authorized reference.

Checkpoint

Create a problem inventory for the hypertension record. Explain why the historical items are not automatically counted, why the clinician's assessment matters, and why neither a long diagnosis list nor a single high-complexity problem completes the overall MDM decision.

Compare your abstraction

The inventory should show the hypertension evaluation, stated status and continued plan. Historical entries without current evaluation or treatment do not automatically become additional addressed problems. Preserve the clinician's assessment, resolve missing facts and keep the problem-element conclusion separate from the final MDM level.

Sources

1. American Medical Association — CPT Evaluation and Management revisions FAQs. Current 2026 page explaining E/M revisions; use current authorized book. Accessed 2026-09-10.