The Phrase That Pays: Problem Addressed vs. Problem Listed
Article Reference Code: NAMAS.04.10.2026
Written by: Keisha Wilson, CHC, CCS, CPC, CPCO, CPMA, CRC, CPB, AAPC Approved Instructor
A Compliance, Coding, and Documentation Perspective
For decades, the 1995 and 1997 Evaluation and Management (E/M) Documentation Guidelines trained us to audit based on “quantity”, counting body systems, history elements, and bullet points to justify a level of service.
However, with the 2021 and 2023 E/M updates, the industry has undergone a fundamental shift. The focus is no longer on volume but on Medical Decision Making (MDM), specifically the “why” behind the encounter. This shift aligns closely with risk adjustment methodologies, emphasizing substance over structure.
One of the most common and costly misconceptions I identify during audits is the confusion between a “problem listed and a problem addressed”. At first glance, the distinction may seem minor. In reality, it represents the difference between compliant documentation and the auditor’s potential recoupment.
The End of the “Laundry List” Era
For years, many of us have encountered what I often call the “laundry list” progress note, populated with extensive diagnosis lists pulled forward through templates. These lists frequently include chronic conditions and histories such as diabetes mellitus, hypertension, chronic kidney disease, Deep Vein Thrombosis, stroke history, or past cancer diagnoses, without clarity on what is active, resolved, or relevant to the current visit.
Historically, these lists were used to inflate the perceived complexity of a visit. Today, under updated guidelines, that approach no longer holds up under scrutiny.
When the AMA revised the E/M guidelines, clarity around what constitutes a “problem addressed” was a welcome change. For auditors and educators, it provided a definitive standard that enabled us to guide providers with evidence-based expectations rather than relying solely on interpretation. We, finally, had somewhere we could have providers validate official guidance and put an end to the “compliance said” comments.
Defining the “Problem Addressed”
When defining the problem addressed, as a compliance auditor and physician educator, I constantly remind my teams of a foundational principle: only problems that are addressed during the encounter may be counted toward MDM. A problem is considered addressed when the provider evaluates, manages, or treats it during that specific encounter.
Many providers fall into what I call the “Phrase That Pays” trap. Some feel pressured to add extra diagnoses to justify more complex or higher-level visits. However, if the documentation doesn’t show the actual work done, those diagnoses risk being flagged in audits rather than generating revenue.
To support the level of care billed, documentation must establish a clear connection between the encounter and the provider’s clinical decision-making. A helpful way to conceptualize this is by bridging two familiar frameworks:
- S.O.A.P. (Subjective, Objective, Assessment, Plan): The structure of the note
- M.E.A.T. (Monitor, Evaluate, Assess, Treat): The evidence of work performed
While M.E.A.T. is commonly associated with risk adjustment, it is equally valuable in supporting E/M documentation by demonstrating that a problem was actively managed/addressed rather than merely listed.
What the Guidelines Require
Under current E/M guidelines, the number and complexity of problems addressed are a key component of MDM. A problem may include a disease, condition, symptom, or finding that is evaluated or treated during the encounter, with or without a diagnosis being established at the time of the encounter. A problem addressed or managed per AMA is: When it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice.
However, the guidance is equally explicit about what does not count. Simply listing a diagnosis without evaluation, assessment, or management does not qualify as addressing that problem. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.
Additionally, referrals alone do not meet the requirement. If a provider documents that another professional is managing a condition but does not include their own assessment, evaluation, or care coordination, that condition cannot be counted toward MDM.
To support compliance, documentation should reflect clear evidence of provider work, such as:
- Reviewing symptoms or patient status
- Evaluating diagnostic tests or results
- Managing or adjusting medications
- Ordering or interpreting tests
- Modifying treatment plans
- Counseling or monitoring conditions
If a condition is merely mentioned in the “Past Medical History” or sits dormant in a “Problem List” without a documented assessment or plan for that date of service, it cannot contribute to the E/M level. Without this activity, the condition is simply part of the patient’s medical history rather than part of the MDM calculation.
Problem Listed vs. Problem Addressed: A Practical Example
A frequent issue identified during documentation audits is the assumption that every diagnosis listed in the assessment automatically contributes to the E/M level. This is incorrect.
For example:
Problem Listed (Audit Risk):
Assessment:
- Hypertension
- Type 2 Diabetes
- DVT
- Stroke
In this scenario, diagnoses are simply listed without any indication of evaluation or management. There is no evidence of work performed, or that the problems are currently being treated or resolved, and there is a history of making it ineligible for MDM consideration.
Problem Addressed (Audit-Supported):
Assessment:
- Hypertension: Blood pressure 130/80 today; continue current Lisinopril
- Type 2 Diabetes: Reviewed recent A1c (6.8); patient compliant with Metformin 500 mg BID; condition stable, no changes
- History of CVA in 2000, pt is neurologically intact. Continue Aspirin 81mg daily for secondary prevention. Monitor BP closely.
- DVT resolved in 2022. Patient is currently off anticoagulants. Use compression stockings during long flights for prophylaxis.
Here, all problems clearly demonstrate evaluation and management, and the provider’s clinical involvement is evident, supporting inclusion in MDM.
Why This Matters in Compliance
From a compliance and auditing perspective, this distinction is critical. When coders and auditors reevaluate encounters, they are looking for clear documentation that supports the E/M level billed.
When unsupported diagnoses are counted, the encounter may be flagged for:
- Downcoding
- Medical necessity concerns
- Overpayment risk
Accurate documentation is not just about compliance; it directly impacts reimbursement integrity.
Guidance for Coders and Providers
For coders, carefully review documentation to determine whether conditions were truly addressed. Ask:
- Is there evidence of evaluation or management?
- Was the condition monitored or treated?
- Was the test ordered or analyzed?
If the documentation does not reflect the work performed, the diagnosis should not be included in MDM. This concept helps coders understand that documentation tells the story of clinical work, and coding must accurately reflect that work. It also reinforces an important principle of compliance: coding must always be supported by documentation.
For Providers, a diagnosis in the problem list is not enough. Documentation must show active involvement. Even brief statements can effectively demonstrate this, such as:
- “Stable on current medication”
- “Reviewed labs; no changes needed”
- “Condition monitored; continue current plan”
These concise entries provide the necessary link between diagnosis and decision-making.
Final Thoughts
Clarity and intent matter more than ever. The distinction between a problem listed and a problem addressed is not just a technicality; it is a cornerstone of compliance, accurate coding, and audit readiness. As I often remind both providers and students, when documentation clearly reflects clinical thought, decision-making, and patient management, it not only supports appropriate reimbursement but also tells the true story of the care provided.
Resources:
https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf
Contact Keisha on LinkedIn by Clicking her Name Below:
Keisha Wilson, CHC, CCS, CPC, CPCO, CPMA, CRC, CPB, AAPC Approved Instructor
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