When “More” Doesn’t Mean “Moderate”

Understanding the Acute Problem Riddle in MDM.

Let’s be honest — it makes sense to assume that if a patient shows up with four acute problems, the visit should reflect a higher level of complexity. After all, managing multiple complaints takes more time, focus, and decision-making, right?

That’s  where the common misunderstanding lies.

Provider effort does not equate to the level of Medical Decision Making (MDM). Rather, the MDM level is determined by the documented risk and complexity of the case which impacts the clinical reasoning required to diagnose, plan, and manage those risks.

The Grid: A Guideline or A Checklist.

Now let’s consider the MDM Grid. It’s easy to fall into the habit of using the Grid primarily as a checklist. When used this way, the essence of the documented encounter is lost, potentially leading to a mis-captured clinical picture. Not to say that the Grid doesn’t have its purpose. In fact, the Grid is critical to the MDM process. However, it should be used as a guideline rather than a checklist.It is an excellent reference tool when measuring the documented clinical picture to each of the three MDM Grid elements. But it is essential that the clinical picture is first understood before applying the Grid.

We start by understanding the purpose behind every encounter.

Why did the patient present for this visit? Before considering the complexity, risk, and data, ask the simplest question: Why was this patient seen today?

That single answer reframes everything. It centers the E/M level on the documented clinical picture, not the checklist.

 

Consider that the patient is in fact presenting with four acute problems. The building of the clinical picture begins.

• • Are these problems straightforward and isolated?

• • Or could some of them be interrelated?

• • Are any of these problems presenting a broader systematic effect?

• • Do any of the problems have an uncertain prognosis?

• • Does the patient have any co-existing chronic conditions that are exacerbated by these acute conditions?

• • Do any of the chronic conditions influence the complexity of the acute conditions?

     

Once the presenting clinical picture is built, clinical reasoning ramps up. It considers such elements as:

• • Which tests and diagnostics were needed? Which were reviewed?

• • Which were not available and needed to be ordered?

• • Which were available but needed interpretation?

• • Were other provider notes or consults reviewed or discussed?

     

From this process, the management and treatment plan for the presenting problem(s) is created. Consider:

• • What decisions were made?

• • What treatments were planned?

• • What medications need to be managed?

• • What follow-ups were planned?

• • What risks need to be considered?

Solving the Riddle: Closing the Gap

Start with the “why.”
Before scoring, anchor every encounter in the patient’s purpose for the visit. Ask, “Why is this patient here today?” It keeps the review centered on the clinical story, not the checklist.

Build the Clinical Picture. Identify whether acute problems are isolated, interrelated, or systemic. Consider if chronic conditions are impacted or influencing the acute issues. Understand the true scope and risk of the encounter before turning to the Grid.

Use the MDM Grid as a Guide — Not a Scorecard. The Grid is a reference tool, not a replacement for clinical reasoning. Measure each element (problems/risk, data, management/plan) in the context of the case, not strictly by count. Remember: More problems ≠ higher complexity. Risk drives the level.

Summarize the Decision-Making Process. Consider what data was reviewed, ordered, or interpreted. Outline treatment and management decisions (tests ordered or reviewed, medications adjusted or prescribed, consults requested, risks considered and mitigated).

Embrace the Gray Areas. MDM is not always black and white — professional judgment matters. Two reviewers may see the same note differently, and that’s okay if the rationale is sound. The goal: a defensible, accurate representation of the documented clinical picture and a correct capture of the clinical reasoning involved.

The Takeaway:

• • The grid doesn’t give “bonus points” for having more acute issues — only for having riskier ones.

• • MDM isn’t about how many problems are addressed — it’s about the complexity, risk, and reasoning behind each one.

• • Use the Grid to support your story, not to define it.

We at Chirok Health strongly believe in making compliance and clinical sense meet — allowing teams to think smarter, document better, and code with confidence.