Charting for Medical Decision Making (MDM) 99204 and 99214
MDM is comprised of the top 2 of 3 considerations: Diagnosis, Data, and Risk. In the ambulatory setting, Diagnosis and Data are more likely to satisfy documentation requirements.
Many templates have time recorded as part of the office visit. Billing can be based on Time or on Medical Decision Making. This document describes the elements required for Medical Decision Making documentation. If the time spent on an office visit is appropriate for a 99213 but the medical decision making supports a 99214, then 99214 is the appropriate code for the encounter.