Evaluation and Management (E/M) Coding and Documentation
This domain tests the E/M rules as they apply to documentation you can actually see. For office and outpatient services 99202–99215, the level is set either by medical decision making or by total time on the date of the encounter - the reporting practitioner chooses which basis to use.
Selecting the service
- Establish the category and setting first: office/outpatient, hospital inpatient, observation, emergency department, nursing facility, home or residence.
- New versus established: a new patient has received no service from the same specialty in the same group practice within the past three years.
- Office codes: 99202–99205 for new patients, 99211–99215 for established. 99211 requires no MDM elements and is not a physician-level service.
Medical decision making: three elements, two must be met
- Number and complexity of problems: minimal; low (stable minor or acute uncomplicated problem); moderate (undiagnosed new problem with uncertain prognosis, acute illness with systemic symptoms, chronic illness with exacerbation); high (threat to life or bodily function).
- Data: limited means at least two Category 1 elements such as ordering or reviewing unique tests and reviewing prior external notes; moderate means at least three Category 1 elements or at least one Category 2 element (independent historian, independent interpretation of another provider's test, discussion with an external provider).
- Risk: moderate includes prescription drug management and minor surgery with risk factors; high includes drug therapy requiring intensive monitoring for toxicity and emergency major surgery.
- Score all three, then take the highest level supported by at least two of the three elements.
Total time
- Count all time on the date of the encounter spent by the reporting practitioner, including chart review, ordering, counseling, and documentation.
- Office thresholds: 99202 15–29 minutes, 99203 30–44, 99204 45–59, 99205 60–74; 99212 10–19, 99213 20–29, 99214 30–39, 99215 40–54.
- Prolonged services begin after the top-level threshold is exceeded - 99417 in 15-minute increments, with a payer-specific equivalent for Medicare.
Worked example
An established patient with one stable chronic condition reports new dizziness. The physician orders and interprets an ECG and a CBC and prescribes meclizine. Problems: undiagnosed new problem with uncertain prognosis plus a stable chronic illness - moderate. Data: two unique tests - limited. Risk: prescription drug management - moderate. Two of three elements reach moderate, so 99214 is supported. If total documented time had been 34 minutes instead, the same 99214 would be supported on time.
Traps that cost marks
- Billing 99211 for a visit with clear moderate MDM - that is undercoding.
- Counting a stable chronic illness as a moderate problem.
- Reporting time when the note never states total time.
- Adding modifier 25 without a separately identifiable service described.
- Treating a consultation as a transfer of care, or missing the three-year new-patient rule.