Beyond the Grid: Are We Misusing the MDM Table?
Article Reference Code: NAMAS.05.01.2026
Written by: Beth Schleeper, COC, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, CPC-I, CEMC, CANPC, CEMA, CMCS, CMRS
Medical Decision Making (MDM) was supposed to make E/M leveling easier. Right? Cleaner. Easier. More consistent. Instead, it’s turned into the coding world’s version of a choose-your-own-adventure story—except everyone is convinced their adventure is the right one, and somehow, we’re all landing on different endings.
Auditors, educators, compliance teams, and providers genuinely are trying to play by the same rules. Effort isn’t the issue. The real problem? We’re over-using, under-using, and straight-up misusing the MDM table. The fallout is real: lost revenue, inflated levels, failed audits, frustrated providers, and compliance headaches no one has time for.
Let’s take a real look at what’s going wrong, why it happens, and how we can get back to using the table the way AMA actually intended.
The MDM Table isn’t a checklist, although we sometimes treat it like one. Here’s the part nobody likes to say out loud: The MDM table is not a scoring tool. Not a points system.
Not a tally sheet. Not a “pick any two and call it a day.” Plenty of organizations still use it exactly that way, like a magic box-checking ritual that spits out a level. It oversimplifies something that is literally called medical decision making, clinical judgment, complexity, clinical reasoning, and risk. If the documentation says, “patient stable, continue meds,” but enough boxes are marked to declare it a level 4? That’s not coding, that’s building a sandcastle. Looks great until the audit tide rolls in.
We focus so hard on the table, we forget the story. Ironically, MDM was designed to be concept-driven, not table-driven. AMA’s narrative definitions hold more weight than the grid. But coders and auditors often reverse that, treating the table like the primary source of truth and expecting the documentation to fit whatever box they want to check. That’s where trouble starts.
Some of the biggest offenders:
Treating data like we’re just scanning items. Ordering three tests does not mean “extensive data.” Reviewing routine labs doesn’t magically upgrade a level. Data is about clinical thinking, not volume. A pile of low-value actions doesn’t morph into high complexity just because it’s bigger.
Inflating the ‘Problems Addressed’ column like a birthday balloon. Mentioning a condition isn’t the same as addressing it. Stable chronic illness does not equal acute exacerbation. A passing comment is NOT active management. If the problem didn’t influence decisions at that encounter, it doesn’t get a seat at the MDM table.
Turning the Risk Column into a worst-case scenario parade. Risk is based on what was actually considered or decided, not every catastrophic possibility. Some notes read like a script for a medical disaster documentary. Coders see the scary words and feel obligated to level up. But AMA doesn’t award “bonus points” for dramatic flair.
The columns only work when the story works. One of the most ignored principles: MDM is the overall level, not the highest checked column. If one column is moderate and everything else is low, you don’t magically get a moderate overall. The bigger picture has to make clinical sense. Too many people cling to the old “two-out-of-three” mindset and forget the bigger picture: MDM should reflect true complexity, not cherry-picking favorable boxes.
Documentation vs. Interpretation: A mismatch made in billing Heaven. Providers document for patient care. Coders document for rules. Compliance documents for risk. Administration documents for revenue. It’s a miracle anyone agrees on anything.
Providers write in shorthand:
“Doing better,”
“Labs OK,”
“Continue same plan.”
Coders are left squinting at the note like it’s a foreign language, trying to reverse-engineer the complexity. And because the table looks objective, they try to fit incomplete narratives into rigid drawers.
Cue:
- overcoding when assumptions get creative
- undercoding when providers think details are “obvious”
- inconsistent audits because “complexity” means something different to everyone
The MDM table was never designed to fix vague documentation. But we keep trying to use it like a decoder ring anyway.
Why we misuse the MDM Table: it feels objective. People love boxes. People love grids.
People love something that looks like math. MDM isn’t math, AMA designed it that way on purpose. It’s supposed to reflect thought process, decision making, not tally marks. We try to force objectivity onto something inherently subjective, and the harder we cling to the table, the more inconsistently we use it.
So How Do We Fix This Without Losing Our Collective Minds?
A few practical steps can drag this whole process back to reality:
- Teach the concepts, not the grid.
AMA definitions matter more than formatting. - Help providers document their reasoning; not write novels.
Just enough detail to capture the complexity. - Stop treating data like a quantity game.
Explain what counts as analysis vs. busywork. - Use real case studies with side-by-side interpretations.
Nothing exposes differences like comparing notes. - Hold team huddles on tricky encounters.
Coders, auditors, and providers aligned will lead to fewer headaches. - And please… stop trying to up-level unsupported notes.
No more “fixing” documentation to “fit the grid.”
The bottom line, the MDM table is a guide, not gospel. When we rely on it too rigidly, we reduce nuanced clinical decision making to a box-checking game. The table can support the process, but it will never replace provider reasoning or auditor judgment. If we want consistent, defensible E/M leveling, we have to get beyond the grid and back to what MDM was meant to do: capture the complexity of clinical thinking, not teach people how to game documentation.
And hey, if the day ever comes when MDM can be perfectly captured by a spreadsheet? mThat’s the day auditors finally get to retire early. I wouldn’t start packing yet.
Contact Beth on LinkedIn by Clicking her Name Below:
Beth Schleeper, COC, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, CPC-I, CEMC, CANPC, CEMA, CMCS, CMRS
Medical Billing Coding Expert, featured on multi-media professional panels to support proper medical administration procedures, A demonstrated history of working in the hospital & health care industry. Skilled in Healthcare Consulting, Medicaid, Billing Services, Physician Relations, and Conference Speaking. Strong entrepreneurship professional with a COC, CPC, CDEO, CRC, CPB, CPCO, CPMA, CPPM, CPC-I, CANPC, CEMC, CEMA, CMRS, and CMCS focused in Medical Insurance Coding Specialist/Coder from the AAPC, NAMAS, and AMBA
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