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Documentation Checklist for MDM-Based Billing Every 99204 note should include these 10 elements: Chief complaint and reason for visit Detailed HPI (location, quality, severity, duration, timing, context, modifying factors, associated signs/symptoms) Review of systems covering pertinent systems Past, family, and social history as clinically relevant Comprehensive physical exam findings Assessment showing problems addressed , not just past medical history Data explicitly reviewed or ordered, naming specific labs, imaging, and external records Risk explicitly stated, tied to a new prescription, surgical decision, or social determinant limitation Plan with treatment decisions, follow-up, and referrals Provider signature and date Items 6, 7, and 8 are where most notes fall apart

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