Every office visit leveled on medical decision making.
New and established patient visits, 99202–99215, leveled consistently under the AMA E/M guidelines, and backed by what the provider documented.
Office and outpatient E/M codes
Since 2021, office visit levels are chosen by medical decision making (MDM) or total time. Code 99201 was deleted, so straightforward new-patient visits are 99202.
We level on medical decision making: the level is the one that two of the three MDM elements support.
| Medical decision making | New patient | Established patient |
|---|---|---|
| Straightforward | 99202 | 99212 |
| Low | 99203 | 99213 |
| Moderate | 99204 | 99214 |
| High | 99205 | 99215 |
The three elements of MDM
Every visit is scored on all three, and the reviewer can see how each one was assessed.
Problems addressed
How many problems were evaluated or treated at this visit, and how complex: self-limited, acute uncomplicated, chronic with exacerbation, undiagnosed with uncertain prognosis, and so on.
Data reviewed and analyzed
Unique tests ordered or reviewed, external notes reviewed, an independent historian, independent interpretation of a test, and discussion of management with an external clinician.
Risk of patient management
The risk of the management options chosen: over-the-counter drugs, prescription drug management, decisions about surgery or hospitalization.
Six E/M coding errors that lead to audits
Each one is checked on every visit.
- 01
Listed, not addressed
Problems on the list that weren't worked on at the visit.
- 02
Referrals as management
Sending a problem on isn't the same as addressing it.
- 03
Results counted twice
Test credit taken at more than one visit.
- 04
Unnamed historians
History from someone else, with no one identified.
- 05
Over-read minor illness
Common symptoms read as a more serious illness.
- 06
The provider's pick
A level that follows the selection, not the note.
Never raised automatically
When the documented level differs from the level the provider selected, the encounter goes to a coder with the reason. Under-coded visits are flagged so documented work isn't lost; over-coded visits are flagged before they become an audit finding.
- Consistent leveling across providers and locations
- Level discrepancies routed to a coder
- Documentation gaps flagged for your team
- Modifier 25 placed when a separate service is billed the same day
See how your E/M levels compare.
We'll level a sample of your past visits and show you where the documentation and the billed levels disagree.