E/M Documentation: MDM Location Requirements
Medical Decision Making (MDM) does NOT need to be documented in a separate section from the Assessment and Plan—it can be fully integrated within the Assessment and Plan section. 1
Current E/M Guidelines on Documentation Format
The current E/M coding guidelines focus on what is documented, not where it appears in the note. 1, 2
Key Documentation Principles
- No format requirements exist mandating MDM be separated from Assessment and Plan sections 1
- Documentation should support the complexity of clinical decision-making regardless of where it appears in the medical record 1, 2
- The American Academy of Family Physicians emphasizes that documentation should focus on supporting patient care and accurately retelling the patient's story, rather than meeting arbitrary format requirements 1
What Must Be Documented (Not Where)
For MDM complexity determination, you must document:
- Number and complexity of problems addressed during the encounter 1
- Amount and complexity of data reviewed, ordered, or analyzed 1
- Risk of complications, morbidity, or mortality associated with the presenting problem(s), diagnostic procedures, and treatment options 1
Common Pitfall to Avoid
Do not create artificial separation between Assessment and Plan and MDM elements simply to satisfy a perceived documentation requirement. 1 This leads to redundant documentation that clutters the medical record without adding clinical value. 2
The American College of Physicians explicitly warns against documentation that includes boilerplate content to satisfy perceived guidelines rather than clinically relevant information. 1
Practical Implementation
Integrate MDM naturally within your Assessment and Plan by:
- Documenting your diagnostic reasoning and differential considerations under each problem 2
- Explicitly stating data reviewed (labs, imaging, records) and your interpretation 1
- Noting the complexity of treatment decisions and risk discussions with patients 1, 2
When using time-based coding, document total time spent including non-face-to-face work on the same day. 1