Medical decision making is the part of an E/M note that shows the problems you addressed, the data you reviewed, and the risk of what you decided. Under the AMA’s CPT guidelines, it sets the visit level, unless you choose by time. Copy the MDM section to the end of any note, see a moderate office visit and a high-complexity emergency visit worked through, and check what counts in each element.
For clinicians in the United States.
Blank medical decision making template
FreeMEDICAL DECISION MAKING Visit type: [Office new or established, hospital inpatient or observation, emergency department, nursing facility, or home] Level chosen by: [MDM, or total time on the date of the encounter where the visit type allows it] PROBLEMS ADDRESSED Problem 1: [Diagnosis or symptom, its status today, and what you evaluated or treated] Problem 2: [Diagnosis or symptom, its status today, and what you evaluated or treated] Status against goal: [At goal, not at goal, worsening, severe, or a threat to life or bodily function, with the finding that shows it] Noted, not addressed: [Conditions another clinician manages that you did not assess today] DATA REVIEWED AND ANALYZED Tests ordered: [Each unique test, and the result that would change the plan] Results reviewed: [Each unique test result with its date, and what it means for this patient] External records: [Each outside source reviewed, with its date and the key finding] Independent historian: [Who gave the history, and why the patient could not give a complete or reliable one] Independent interpretation: [Your own read of an ECG, image, or tracing that another clinician will report] Discussion of management: [Who you spoke with outside your group or specialty, when, and what you decided together] RISK OF PATIENT MANAGEMENT Decisions made: [Medications started, changed, continued, or stopped; procedures; tests; the level of care] Options considered, not chosen: [What you discussed and decided against, and why] Social determinants: [Housing, food, cost, or transport problems that limit the diagnosis or treatment, and how] MDM LEVEL Problems: [Minimal, low, moderate, or high] Data: [Minimal or none, limited, moderate, or extensive] Risk: [Minimal, low, moderate, or high] Level: [Straightforward, low, moderate, or high, and the two elements that set it] Total time, if used instead: [Minutes on the date of the encounter, and what they covered] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Primary care office, established patient, 3-month follow-up
Office visit, established patient. Level chosen by MDM. 61-year-old man with hypertension and type 2 diabetes.
1. Hypertension, not at goal. Home readings average 152/94 over 14 days. Office BP 156/96, and 154/94 on repeat after 5 minutes seated. Goal under 130/80. Takes lisinopril 20 mg daily every day. No chest pain, headaches, or ankle swelling. 2. Type 2 diabetes, at goal. A1c 6.8% on metformin 1,000 mg twice daily. No low readings. Feet: sensation and pulses normal.
Reviewed: A1c 6.8%, drawn 5 days ago on his standing order. Ordered: basic metabolic panel in 2 weeks, to check potassium and creatinine after the dose change. No outside records. Count: 2 items in the first data group.
Prescription drug management: lisinopril increased from 20 mg to 40 mg daily. Metformin continued at 1,000 mg twice daily, with his A1c at goal. Adding amlodipine 5 mg daily discussed as the other option; he chose the dose increase. Told to report dizziness on standing. Recheck BP and the home log in 4 weeks.
Problems: moderate, a chronic illness not at goal, alongside a second chronic illness. Data: limited. Risk: moderate, prescription drug management. Level: moderate, set by problems and risk. Data didn’t need to reach moderate, because two of three is enough. Office visit, established patient, moderate MDM: 99214.
Emergency department, adult brought in by family, admitted
Emergency department visit. Level chosen by MDM; time isn’t used for emergency visits. 72-year-old woman with atrial fibrillation on apixaban 5 mg twice daily, brought in by her husband after fainting at home.
1. Upper GI bleed with low blood pressure and fainting, a threat to life: black, tarry stools for 2 days; fainted in the bathroom this morning. On arrival BP 92/56, HR 114. Took ibuprofen 400 mg three times a day for knee pain this past week. Glasgow-Blatchford score 16. 2. Acute blood loss anemia: hemoglobin 7.8 g/dL, 12.6 in March. 3. Atrial fibrillation on anticoagulation: rate 112, likely to settle with volume; no rate-control drug while her blood pressure is low.
Ordered and reviewed: CBC, comprehensive metabolic panel, INR, type and screen, and troponin. Hemoglobin 7.8 g/dL, BUN 48 mg/dL, creatinine 1.0 mg/dL, INR 1.3, troponin normal. External record: her cardiologist’s March clinic note, with the baseline hemoglobin. Independent historian: her husband, because she doesn’t remember the faint; he found her on the floor, awake within a minute, with no shaking. Independent interpretation: ECG at 9:12 a.m., my read: atrial fibrillation, rate 112, no acute ST changes; cardiology will report it. Discussion: phoned Dr. Lena Ortiz, gastroenterology, at 10:05 a.m.; agreed on IV pantoprazole, holding apixaban, no reversal agent while she responds to fluids and blood, and endoscopy within 24 hours.
Decision regarding hospitalization: admitted to the step-down unit under hospital medicine, accepted by Dr. Sam Patel at 10:30 a.m. Intensive care considered; step-down chosen because her BP rose to 108/64 and HR fell to 98 after 1 L of lactated Ringer’s and 1 unit of packed red cells. Pantoprazole 80 mg IV. Apixaban and ibuprofen held. Wants full treatment; full code, confirmed with her and her husband.
Problems: high, an acute illness that poses a threat to life. Data: extensive, with all three data groups met where two were needed. Risk: high, the decision about hospitalization. Level: high, on all three elements; any two would have been enough. Emergency department visit, high MDM: 99285.
The AMA’s CPT guidelines define the elements and levels of MDM, and CMS applies them to Medicare E/M claims. The descriptions on this page are our own summary of the AMA’s table, not a copy of it.
Which E/M family the visit belongs to, and whether you are choosing the level by MDM or by time. The same MDM level matches a different code in each family.
Avoid: Recording total time to choose an emergency department level. Time doesn’t set the level there; MDM does.
Each problem you evaluated or treated today, and how serious it is now. A problem counts because you addressed it, not because it is on the problem list.
Avoid: “Stable” for a chronic illness that isn’t at its treatment goal. The AMA’s guidelines count a patient who hasn’t reached the goal as not stable, even if nothing has changed.
What you ordered, reviewed, and worked out, in three groups: tests, documents, and independent historians; your own interpretation of a test; and a discussion with an outside clinician.
Avoid: Counting a test twice. A test is counted at the visit where you order it, not again when the result comes back, and a test whose interpretation you bill separately doesn’t count here at all.
The risk of what you decided, or seriously considered, for the problems you addressed. This is the risk of the management, not of the disease.
Avoid: Leaving out what you decided against. A hospital stay you weighed and didn’t order still counts toward risk, but only if the note says so.
Your rating of each element, and the level that two of the three reach. A reader should see which two from the note alone.
Avoid: A level with no reasoning behind it. If an auditor can’t match the level to two elements in the note, it won’t stand.
Other conditions count only when you address them today, or when they make the data or the risk more complex. Write what you did for each problem, and leave the rest in the history.
A chronic illness that hasn’t reached its treatment goal isn’t stable for MDM, even when nothing has changed. Write the goal and the reading that misses it.
A test you considered and didn’t order, or a hospital stay you weighed and avoided, counts only when the note gives it and the reason.
A discussion counts when it is a direct, two-way exchange with an outside clinician or an appropriate source. Sending notes doesn’t count, and neither does a message passed through staff. Write who, when, and what you agreed.
A long history, a pasted exam, or a copied review of systems doesn’t raise the level. Their extent isn’t an element in choosing it, and CMS says the volume of documentation must not decide it.
An independent historian gives a history of their own, because the patient can’t give a complete or reliable one, or because you need it confirmed. An interpreter doesn’t count.
Vero Scribe writes the note in your template, MDM section included, from the visit conversation with the patient’s consent, or from your dictation. You review and edit every section and choose the level yourself, then copy the note into your record or export it to Word or PDF. Vero works in 60+ languages.
The part of an evaluation and management note that shows how you reached your decisions: the problems you addressed, the data you reviewed and analyzed, and the risk of the management you chose. Under the AMA’s CPT guidelines, the MDM level or the total time sets the level of most E/M visits.
The number and complexity of problems addressed at the visit; the amount and complexity of data reviewed and analyzed; and the risk of complications, morbidity, or mortality from patient management. Each element gets a level, and the visit’s MDM is the highest level that two of the three meet or exceed.
Straightforward, low, moderate, and high. For an established patient in the office they match 99212, 99213, 99214, and 99215; for a new patient, 99202 to 99205; in the emergency department, 99282 to 99285. 99211 and 99281 don’t use MDM.
Moderate covers problems such as a chronic illness that is worsening or not at goal, two or more stable chronic illnesses, or an acute illness with systemic symptoms, with risk such as prescription drug management. High covers a severe exacerbation or a threat to life or bodily function, data from at least two of the three data groups, and risk such as a decision about hospitalization or a drug that needs intensive monitoring for toxicity. The two examples above show one of each.
Managing a prescription drug for a problem you addressed: starting, stopping, or changing it, or deciding to continue it after weighing its risks for this patient. The AMA has said that simply reviewing a medication list doesn’t count. Write what you decided and why.
Someone such as a parent, spouse, guardian, or witness who gives a history because the patient can’t give a complete or reliable one, for example because of dementia or a young age, or because you judge a confirming history necessary. An interpreter doesn’t count. Write who it was and why you needed them.
Your own read of a test that has a CPT code and is normally interpreted or reported, such as an ECG, X-ray, or CT, when you aren’t the one reporting it. It doesn’t need to be a full formal report, but write what you saw.
For office, hospital inpatient and observation, nursing facility, and home visits, yes: you can choose the level by your total time on the date of the encounter, including time spent that day without the patient, such as reviewing records. Emergency department levels can’t be chosen by time.
Yes. Copy it, or download it as a Word or text file. No account needed.
The SOAP note reordered: assessment and plan on top, with the history and findings below to back them.
For clinical phone calls and nurse triage: the caller, red flags, advice, disposition, and who calls back.
The chart note for a refill or renewal between visits: last fill, monitoring due, safety checks, the decision, and who approved it.
Your chart note on a lab or imaging result: the value and trend, urgency, action, patient contact, and tracking.
The record of a team or family care conference: attendance, consent, each discipline’s update, decisions, and actions with owners and dates.
Problem-by-problem assessments and plans, drafted from the visit for your review.
From the encounter note to ICD-10 suggestions and team review.
Notes, visit details, and documents together for the handoff to billing.
Structured emergency department notes, with the disposition kept clear.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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