Determining E/M Service Codes using Medical Decision Making (MDM) & Time

Determining E/M Service Codes using Medical Decision Making (MDM) & Time

Overview

The Medical Decision Making (MDM) feature in ICANotes+ is designed to help clinicians document and evaluate patient encounters in accordance with the American Medical Association (AMA) 2023 Evaluation and Management (E/M) Guidelines. These guidelines define MDM as a process based on three key elements:

  1. Number and complexity of problems addressed during the encounter
  2. Amount and/or complexity of data to be reviewed and analyzed, such as tests, documents, orders, or consultations
  3. Risk of complications and/or morbidity or mortality associated with patient management decisions
To determine a specific MDM level, at least two of the three elements must meet or exceed the criteria defined by the AMA.

The MDM feature in ICANotes+ simplifies this process by:

  1. Allowing clinicians to record and classify patient problems based on severity and stability
  2. Supporting documentation and review of diagnostic data and tests
  3. Providing structured options to document management risks and link them to defined risk levels (Low, Moderate, or High)
  4. Displaying the corresponding MDM level (Straightforward, Low, Moderate, or High) based on selected elements

In addition to MDM-based coding, ICANotes+ also supports time-based coding. When clinicians choose this method, the system determines the E/M service level using total encounter time. Time can be populated automatically from the appointment duration, pulled from time recorded in the note, or manually entered—giving clinicians flexibility in how they document their encounters.

By supporting both MDM-based and time-based coding, this feature ensures accurate documentation, appropriate E/M level selection, and compliance with AMA coding standards.

Reference

The Medical Decision Making (MDM) feature is based on guidelines provided by the American Medical Association (AMA). For detailed information, refer to the following document:

Applicability of the Feature

The MDM feature is available in the following note types:
  1. Quick Note
  2. SOAP Note
  3. Progress Note
  4. Primary Care Note
  5. Complete Evaluation

Step 1: E/M MDM Coding Feature – Eligibility & Activation

The E/M MDM Coding feature is available only to practices with an active annual contract. Practices using a self-service or trial subscription are not eligible for this feature.

Notes
If your practice is eligible and you’d like to add the feature for your clinicians, contact our customer support team at ticket@icanotes.com. They’ll help activate the feature and ensure billing updates appear on your next invoice.

Important Notes

  1. Only prescribers can access the MDM feature.
  2. Administrators must assign permissions to users to enable access.
  3. In the Coding Matrix, previously selected values remain saved even if you leave the page.

Step 2: Grant Access to the Feature

By default, administrators have access to the MDM feature. To grant access to other users:

To grant access:

  1. Go to Settings > Practice Settings > Roles & Permissions.

  2. Create a new role or edit an existing role.

  3. Expand the Notes tab.

  4. Select the E/M MDM Coding checkbox.



Step 3: Access the MDM Feature

You can access the MDM feature within multiple note types. For example, when you open a Progress Note, the MDM button appears at the top of the screen.

Select MDM to document:

  • Problems addressed

  • Data reviewed or analyzed

  • Risk level associated with the encounter





Step 4: Use Coding Matrix to Determine Service Code

Selecting the MDM button opens the Coding Matrix, where you can record details to determine the service code.

Problem Addressed:  In this section, each field includes a dropdown menu where you can select the number of problems addressed along with their complexity. The available options are:
  1. Minor Problems
  2. Stable Chronic Illness
  3. Acute, Uncomplicated Illness
  4. Chronic Illness with Exacerbation
  5. Undiagnosed New Problem
  6. Acute, Systemic Illness
  7. Acute, Complicated Injury
  8. Chronic Illness with Severe Exacerbation
  9. Acute, or Life-Threatening Illness

Data Reviewed/Analyzed: In this section, each field includes a dropdown menu where you can select the number of data items reviewed or analyzed during the encounter. The available options are:
  1. External Notes Reviewed
  2. External Tests Reviewed
  3. Tests Ordered
  4. Independent Historian
  5. Independent Interpretation
  6. Discussion and Management

Risk: Select one of the following risk levels:
  1. NA
  2. Minimal
  3. Low
  4. Moderate
  5. High



As you make selections in these three sections, the MDM Level is automatically calculated.
The corresponding service code is also displayed.
To include this code in the note, click Insert <<service code>> in Service Codes.



Step 5: Use Time-Based Coding 

You can also determine the MDM level using time-based coding.

Select the Use Time-Based Coding checkbox. The system calculates time using a defined priority sequence:

  1. Appointment Duration (Highest Priority): If the encounter is linked to an appointment, the system first uses the appointment duration to populate the time.

  2. Time Recorded in the Note: If no appointment is linked, the system checks whether time was recorded in the note using the Time Spent button and uses that value.

  3. Manual Entry (Overrides All): If you manually enter the time in minutes, this value takes precedence and overrides any system-populated time.

The MDM Level automatically updates based on the final time value used or entered.

Notes
When time-based coding is selected, the Problems, Data, and Risk fields are disabled.




Step 6: Include the Narrative in Compiled Notes

As you record details in the Problems Addressed and Data Reviewed sections, a narrative is automatically generated.

To include this narrative in the compiled note, select the Include Narrative in Compiled Note checkbox.




Step 7: Manually Select the 'New Patient' Option 

When recording a service code using the MDM method for new clients, select the New Patient checkbox as shown below. The system will then determine and insert the corresponding service code into the note.

To view the list of service codes available for new clients, click the right arrow icon in the top-right corner of the screen. Reference screenshots are provided below.








Step 8: Review MDM Level and Insert Service Code in the Note

After determining the MDM level (using either the Coding Matrix or time-based method), review it in the bottom-right corner of the screen.
Click the Insert <<service code>> in Service Codes button to include it in the note.
When you compile the note, the service code appears in the compiled version.




Step 9: View Service Code in the Note

The inserted service code appears directly in the note and is also displayed in the compiled version.

Notes
To ensure the service code appears in the compiled note, set Include Service Code in Note to Yes under the Service Codes box.





FAQs 

You can find the Frequently Asked Questions (FAQs) on our Knowledge Base page.


Click here for quick access to the FAQs.

Need Help?

For further assistance, contact:
📞 Phone: 443-203-5857
📱 Text: 866-301-0085
📧 Email: ticket@icanotes.com
💬 Chat: https://app.icanotes.com

Proprietary Notice Information: This article is provided for informational purposes only, and the information herein is subject to change without notice. While every effort has been made to ensure that the information contained within this article is accurate, ICANotes cannot and does not accept any type of liability for errors in, or omissions arising from the use of this information.


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