Welcome to The Coding Corner, a space where doctors who are already excellent at doctoring can dig into the finer details of coding, documentation, compliance, and the occasional mystery that is the AMA Evaluation and Management (E/M) grid. Each month, Tonya Reynoldson, OD, brings forward real-world coding questions we commonly hear in eyecare practices, and she and Sarah Haney break them down from both clinical and coding perspectives.

As an expert clinician, former private practice owner, and passionate educator among her peers, Dr. Reynoldson brings the real-world provider perspective to these discussions. As a coding specialist and internal auditor, Sarah Haney helps analyze these scenarios through the lens of coding guidelines, documentation standards, payor expectations, and audit risk.

From modifier confusion, to medical necessity, to “Wait…why doesn’t this count towards MDM?” moments, this column is designed to make coding guidance feel a little less intimidating and hopefully a little more entertaining along the way.

This month, we address the question, “Why can’t I count this as an undiagnosed problem with uncertain prognosis?”

Dr. Reynoldson: I was recently helping one of my peers work through the Problems Addressed portion of AMA E/M Medical Decision Making (MDM), and this question came up: If a patient comes in with new onset blurry vision and we do not know what it is when they arrive, why can’t that be categorized as an "undiagnosed new problem with uncertain prognosis"?¹

It’s a fair question. After all, doesn’t every new complaint begin with at least some level of uncertainty?

Sarah Haney: This is one of the most common E/M questions in eye care and honestly one of the easiest places to accidentally overstate MDM. Before we break it down, let’s quickly revisit the elements that determine MDM under the AMA E/M guidelines. The level of E/M is established by defining these 3 categories:

1. Problems addressed

2. Data reviewed/analyzed

3. Risk of complications and/or morbidity of patient management

For the Problems Addressed portion of the grid, understanding the AMA’s definition of the terms matter.

An "undiagnosed new problem with uncertain prognosis" does not simply mean the patient arrived with symptoms you didn’t yet know the answer to. If that were the case, every patient with blurry vision, flashes and floaters, diplopia, or headaches would automatically qualify, and my interpretation is that the AMA did not intend for the grid to work that way.¹

The real question is this: After your professional assessment, is the condition still uncertain? That distinction changes everything.

Think about the entire patient journey after your exam, testing, and assessment. Were you able to identify the diagnosis and establish a treatment plan? Or are you still in the process of determining what is actually happening?

Dr. Reynoldson: I’m following you. Let’s run through a couple of clinical scenarios.

For example, let’s say a patient presents with blurry vision, pain, redness, tearing, and light sensitivity, but after your assessment you determine the issue is a central corneal ulcer. You recommend starting antibiotics and discontinuing any contact lens wear. The patient is also scheduled for a follow-up appointment. In that scenario, the problem is no longer undiagnosed or uncertain. You identified the condition, created a treatment plan, and reasonably expect improvement with compliance to the treatment plan.

On the other hand, imagine a patient presents with new blurry vision, and after examination you remain concerned about a possible neurological process, retinal pathology, or systemic disease. Additional testing, imaging, monitoring, and a referral to a specialist is required because the diagnosis and prognosis are still unclear. That scenario is much more consistent with an "undiagnosed new problem with uncertain prognosis."²

Sarah Haney: You got it. A good rule of thumb is this: If you can confidently name it, explain it, and treat it, it probably is not still undiagnosed with uncertain prognosis. The AMA framework is really trying to capture provider cognitive work and clinical uncertainty that remains after the encounter, not simply uncertainty at the chief complaint.

Let’s be honest: Sometimes the E/M grid feels less like coding and more like trying to narrate everything your clinical brain already did automatically. The challenge is that providers often make incredibly complex medical decisions in seconds, but the medical record ultimately has to “show the work.” In many ways, documentation is simply the story of your clinical thought process, and telling that story clearly is one of the strongest defenses you have when supporting appropriate billing, medical necessity, and patient care decisions.

Once you shift your mindset from what symptoms did the patient walk in with? to what uncertainty remained after my assessment? the E/M grid becomes much easier to navigate.

Until next time, stay sharp, stay compliant, and remember: Just because the prognosis is uncertain doesn’t mean your coding has to be.OM

The Coding Corner Crew - Sarah Haney, CHC, CPMA, COPC & Tonya Reynoldson, OD

Tonya M. Reynoldson, OD, MBA is a senior eye care director for AEG Vision. She currently supports over 100 ODs with clinical needs, such as billing and coding questions, electronic health record training, continuing education needs, and clinical staff training to create the best patient outcomes. She previously owned 2 private practices for over 20 years before her current role.

Sarah Haney, CHC, CPMA, COPC is a coding specialist, internal auditor, and senior manager for coding and compliance education.

References

1. American Medical Association. CPT Revised Medical Decision Making Grid. January 1, 2021. Accessed June 11, 2026. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

2. American Medical Association. CPT Evaluation and Management (E/M) Descriptors and Guidelines. January 1, 2023. Accessed June 11, 2026. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf