Problems Addressed: The Most Misunderstood Part of E/M Coding

A diagnosis appearing in the medical record does not automatically count toward the E/M level. In this episode, Stephanie and Michele break down one of the most misunderstood elements of medical decision-making: the number and complexity of problems addressed. They discuss the difference between problems that are listed, mentioned, monitored, evaluated, and actively managed—and explain how terms such as stable, worsening, exacerbated, acute, and uncertain affect code selection. Using practical examples, they show why the same diagnosis can support different E/M levels and what documentation is needed to demonstrate the provider’s work.