- Count every problem addressed, including stable chronic conditions; two of them reach moderate on their own.
- Data credit comes from tests ordered or reviewed, outside records, discussions with other clinicians, and your own independent interpretation of imaging, each named specifically.
- Prescription drug management alone reaches moderate risk; an over-the-counter recommendation does not, even written on a prescription pad.
- The most expensive habit in outpatient coding is reflexive undercoding: defaulting to a level 3 for visits that document level 4 work.
What feels routine to you is often high complexity
Reading your own emergency film, weighing surgery in a diabetic patient, deciding against an intervention: these feel ordinary because you do them daily. CMS scores them as high-level decision making.
The Four MDM Levels and the Codes They Correspond To
| MDM Level | New Patient CPT | Established Patient CPT | wRVUs (New / Est. Patient) |
|---|---|---|---|
| Straightforward | 99202 | 99212 | 0.93 / 0.70 |
| Low | 99203 | 99213 | 1.60 / 1.30 |
| Moderate | 99204 | 99214 | 2.60 / 1.92 |
| High | 99205 | 99215 | 3.50 / 2.80 |
The Three Columns, and Why You Only Need Two
Two columns at a level carry the visit: a complex problem plus a prescription is moderate with no data review, and heavy data can pull up a simple problem.
Column 1: Problems Addressed
The key word is addressed: evaluated, treated, or managed at this visit, not merely noted. Diabetes in the past medical history does nothing; "reviewed glucose control, stable on current therapy, continued" counts.
- Straightforward: one self-limited or minor problem, such as a cold, a minor laceration, or a wart.
- Low: two or more self-limited problems, or one stable chronic illness, or one acute uncomplicated illness.
- Moderate: one or more chronic illnesses with exacerbation, progression, or side effects of treatment; or two or more stable chronic illnesses; or one undiagnosed new problem with uncertain prognosis; or one acute illness with systemic symptoms.
- High: one or more chronic illnesses with severe exacerbation, progression, or side effects; or one acute or chronic illness or injury that poses a threat to life or bodily function.
Three categories get scored too low. Stable versus exacerbated chronic illness: "Type 2 diabetes, stable at goal" is low; "Type 2 diabetes with worsening control, adjusting therapy" is moderate. The new problem with uncertain prognosis: a new breast lump, unexplained weight loss, or a new neurologic symptom under workup is moderate before any diagnosis. The acute illness with systemic symptoms: fever or malaise makes it moderate.
One line does it: "Managed hypertension and type 2 diabetes; both at goal on current therapy. Adjusted metformin dosing given recent weight change." Two stable chronic illnesses, moderate. Could a coder tell from your assessment how many problems you addressed and how sick the patient is?
Column 2: Data Reviewed
Nothing here scores unless it is documented, which is why this column is most often left blank.
- Straightforward: minimal or no data.
- Low: a limited amount; any two category 1 items, such as tests ordered, results reviewed, or external notes reviewed, or use of an independent historian.
- Moderate: review external records and order or review tests, or obtain independent interpretation of results, or have an independent discussion about the patient's management with an external physician or other qualified professional.
- High: an extensive amount; combine review of external records, independent interpretation of tests, and discussion with external clinicians.
Three kinds of effort are tallied. Tests and records: each unique test ordered or reviewed, outside records reviewed, or history taken from someone other than the patient. Ordering a test includes its later review; the same result earns nothing next visit. Discussion with another clinician: a genuine two-way exchange about this patient's management with an external physician or other qualified professional, not a curbside formality; document who and about what. Independent interpretation: personally interpreting a study someone else ordered or performed, and that you are not separately coding. Most clinicians get this one wrong.
The classic case is an electrocardiogram formally read by another physician who codes for that interpretation; your own documented read counts because the order and the coded interpretation belong to someone else. A routine lab result has no professional read to interpret and counts under tests reviewed. No credit for a test you ordered and read yourself, or one you code separately. Record who ordered the study, the date, and your read; a formal report is not required.
Name the data. "Reviewed today's in-office HbA1c and basic metabolic panel. Reviewed outside cardiology note from three months ago" is test review plus external records, moderate. "Labs reviewed" leaves the credit on the table.
Column 3: Risk
- Minimal: over-the-counter drugs; rest or other supportive care.
- Low: minor surgery with no identified risk factors; managing an over-the-counter medication.
- Moderate: prescription drug management; a decision about minor surgery with identified patient or procedure risk factors; a decision about elective major surgery without identified risk factors; a diagnosis or treatment significantly limited by social determinants of health.
- High: drug therapy requiring intensive monitoring for toxicity, such as anticoagulants or immunosuppressants; a decision about elective major surgery with identified risk factors; a decision about emergency major surgery; a decision about hospitalization; a decision not to resuscitate or to de-escalate care because of poor prognosis.
Prescription drug management is broad: starting, refilling, adjusting, or discontinuing a prescription, or continuing one with documented reasoning. It is the most common path to a level 4. The trap auditors look for: an over-the-counter drug written on a prescription pad is still non-prescription, low risk, a level 3, unless the strength is higher than what is sold over the counter. And a prescription is one column; the level 4 needs a second, usually the problem addressed.
Two situations are easy to miss. A decision about hospitalization, including sending home a patient who could reasonably have been admitted, is high risk. A diagnosis or treatment significantly limited by social determinants of health, such as a patient who cannot afford a medication or lacks transportation to follow a plan, is moderate.
Show the risk in the plan: "Continuing metformin 1000 mg twice daily; will monitor renal function given mild chronic kidney disease and recheck a basic metabolic panel in three months." For procedures, name the procedure, its global period, and any patient factors that raise the risk.
Two Notes, Same Patient
Both notes describe a 62-year-old returning with worsening knee osteoarthritis, started on a prescription anti-inflammatory. The long note is the old style; the short one earns more.
HPI: 62-year-old returns with right knee pain, present for several years and gradually worsening. Medial, aching, about 6 out of 10. Worse with stairs and prolonged standing, better with rest and ice. No locking or giving way, no recent trauma. Partial relief with acetaminophen.
ROS: Constitutional, eyes, ear/nose/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurological, psychiatric, endocrine, hematologic, and allergic systems reviewed, negative except as noted above.
Exam: Well-appearing, no distress. Heart regular. Lungs clear. Abdomen soft. Right knee: no effusion, full range of motion, mild medial joint line tenderness, ligaments stable, no warmth. Left knee normal. Neurologic exam grossly intact.
Assessment: Knee pain.
Plan: Recommend NSAIDs and activity modification. Return as needed.
HPI: 62-year-old with known right knee osteoarthritis, returning with a three-week flare. Now limiting walking to less than two blocks and interfering with work. Acetaminophen no longer controlling it.
Exam: Right knee with small effusion, medial joint line tenderness, crepitus with motion, stable. Antalgic gait.
Assessment: Osteoarthritis of the right knee with acute exacerbation, now limiting ambulation.
Plan: Personally reviewed today's weight-bearing radiographs, showing medial joint space narrowing without acute change. Started meloxicam 15 mg daily (prescription drug management), gastrointestinal precautions reviewed. Discussed activity modification, a future corticosteroid injection, and referral for surgical evaluation if symptoms progress. Follow up in six weeks.
Note A supports 99213, worth 1.30 wRVU; Note B supports 99214, worth 1.92, a gap of 0.62 wRVU per visit. The history and exam in Note A are not wrong; they no longer move the level. Naming the problem, the data, and the risk does.
Choosing Your Level: Common Mistakes and How Auditors Think
The most widespread outpatient coding mistake is not overcoding; it is defaulting to 99213 for visits that meet 99214 criteria. It feels safe, but a coding distribution that does not match clinical reality is itself a compliance risk, and bloat has its own: a copied-forward fourteen-point review of systems or an exam that was not performed undermines credibility under audit.
Auditors, from your compliance department to a CMS Recovery Audit Contractor, look for statistical anomalies and documentation-to-code mismatches. Far more level-5 visits than your peer group is a flag, not because level 5 is wrong but because each must be justified note by note; high modifier 25 use or procedure-to-E/M ratios draw the same scrutiny.
A self-check: take five recent notes you coded 99213. Did you address two or more problems, or one not fully controlled? Review labs, images, or outside records? Manage a prescription? If two of three are true, the visit was very likely an undercoded 99214. Check both routes at each encounter, MDM and total time (including pre-visit and post-visit work), and use whichever the documentation honestly supports.
New patient codes (99202-99205) carry higher wRVU values than their established equivalents at the same MDM level. A patient is new only if no provider in your group of the same specialty and subspecialty has seen them face to face in the past three years; a different office location does not reset it, and a same-specialty partner's visit last year makes the patient established to you. For payers that still recognize consultation codes, a referred new patient with no planned follow-up is often better coded as a consultation, which typically pays more; Medicare eliminated consult payment in 2010. The request-opinion-report requirement is in the consultation codes guide.
Three Visits, Worked Through
A straightforward upper respiratory infection
A healthy adult with three days of cough and congestion, no red flags: one self-limited problem, minimal data, low risk, supportive care and an over-the-counter decongestant. A level 3 established visit (99213); the over-the-counter recommendation does not raise it.
The same cough, in a patient with poorly controlled diabetes
Same cough, but the patient's type 2 diabetes is running high and you adjust the medication. An acute illness plus a chronic condition not at goal, and a prescription managed: problems and risk both moderate. A level 4 (99214), if the note states the diabetes assessment and the medication change.
A new patient with several active problems
Hypertension, hyperlipidemia, and new-onset atrial fibrillation; you order an ECG and labs, start an anticoagulant, and arrange cardiology follow-up. Multiple chronic conditions, one new and serious, data across more than one category, and high-risk medication management: a level 5 new patient (99205). The level is what the note shows you addressed, reviewed, and decided.
Sources and Further Reading for This Chapter
- American Medical Association, Evaluation and Management (E/M) Coding. https://www.ama-assn.org/topics/evaluation-and-management-em-coding
- CMS, Physician Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician