The #1 MDM Mistake Auditors Still Catch in 2026

You would think that after all this time, our education would catch up and MDM problems would be cured, yet here we are in 2026- 5 years later still discussing. We still see the MDM be overvalued due to the number of problems being overvalued in documentation. 

It is common to see a note that lists five or six conditions, and at first glance, it may seem like a high-level visit. But when we take a closer look, we find that only one of the conditions were actually addressed during the visit. Many times, it was even a simple issue, maybe even an acute issue- not even one of the chronic conditions. EMR coding wizards, algorithms, and maybe even misunderstood physician training noted, hey- I see multiple chronic conditions in the documentation- BOOM- that’s a level four, baby!

Multiple chronic problems absolutely can be a level four (baby), but only when they are problems addressed in the encounter on that date of service. Merely listing multiple problems does not increase complexity. To be considered as a problem addressed, the provider must evaluate, manage, or make decisions regarding the condition on the date of service, and that must be recorded in the documentation. This is the key point that continues to be missed.

There is another layer to this problem that is often overlooked. Providers sometimes do consider certain problems during their clinical decision-making process but fail to include that thought process in the documentation. For example, a patient may present with an acute uncomplicated issue, such as a headache or joint pain. However, that patient may also have significant comorbidities like hypertension, renal impairment, or diabetes. These comorbidities must be considered when determining an appropriate treatment plan, especially when over-the-counter medication options are being discussed. We often see that the provider includes these comorbid diagnoses in the record, but there is no documentation of how they impacted the treatment decisions. In these cases, a valid problem has been addressed, but without appropriate documentation, it cannot be counted toward the complexity of MDM.

This is a great starting point for those who educate physicians. Before reviewing how to assign a level, ask a few direct questions. What was managed today? Were any decisions made? Was anything different or new that required clinical judgment?

Documentation should reflect the work of the encounter, not just a copy of the patient’s problem list. That shift in thinking can help improve the accuracy of MDM level selection.

A long list of problems might look impressive. But from an auditing perspective, it just signals that we need to look a little closer. What we are really looking for is the substance behind the note.

The level of service should always reflect the work performed. That is what supports the code. And that is what holds up to audit.