Please Help Me Document Properly for MDM

[SoulinNeed]

I've routinely been billing E/M with a therapy add on, but I recently found out (don't worry, I'm a new grad) that you can't use therapy add on codes if you're billing E/M based on time. My appointments are long enough to include 16 minutes of therapy. I'm just not familiar with MDM documentation, though I'm sure I've been doing it forever in residency. I have a HPI, ROS (10 parts), MSE, review labs (if available), with A/P based on problems, with therapy, primarily supportive. However, what line should I throw in at the end to show that I'm properly managing someone to justify a 99214+90833? Or am I overthinking this?

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[SoulinNeed]

Take a look at the chart on pages 7 and 8. For 2021 onward the documentation requirements became a lot easier. You need to document a medically appropriate history and exam. What’s medically appropriate is determine by the doc and there isn’t a requirement here for billing purposes. I write long notes personally but there is not a billing purpose need for an HPI, ROS, or MSE. The A/P is what counts.

My notes generally have in the subjective section two paragraphs where I’ll discuss all the problems addressed and a social determinants of health section. I make two paragraphs for billing purposes ie the two problems MDM criteria. One paragraph has one or multiple problems we addressed contained within. The other paragraph has one or multiple other problems we address that were not addressed in paragraph 1.


My objective has an MSE and vitals.

My A/P is where the meat is at. I track past labs here and relevant medicine trials here rather than in the objective so I can better know when it’s time to order new ones or quickly review past trials. Works for me

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

I guess my confusion always comes in because as a resident, I would see attendings attest notes with a few sentences of "patient of moderate or high complexity etc. etc.", and I'm like, should I have something like that in my note?