Under the rules in force since 2021 and unchanged for 2026, the level is set by medical decision making, which has three parts:
- the problems you addressed,
- the data you reviewed, and
- the risk of your plan.
Two of the three at a level support that level. Below are the phrases that document each one. They are prompts for what to write when it is true, never a script for work you did not do.
Levels 2 and 3
Straightforward and low complexity are real levels for real visits: one self limited problem, one stable chronic condition with nothing else, a refill. Use them when that is what happened. The audit finding across specialties is not that physicians overuse 2 and 3; it is that they use them for visits that were actually 4s.
Phrases that support a level 4
Moderate complexity. Two of the three columns below at this level make the visit a 99214 or 99204.
Problems addressed
Addressed two or more stable chronic conditions: *** and ***, both reviewed and managed today.
Addressed one chronic illness with progression: ***, now *** (worsening or not at goal), plan adjusted accordingly.
Not at goal is the phrase that matters. Diabetes with an A1c that is improving but still above target is a chronic illness with progression, not a stable one; stable means at the treatment goal.
Addressed one acute illness with systemic symptoms: *** (problem) with *** (symptoms).
Data reviewed
Reviewed *** (three or more of: external notes from ***, results of ***, tests ordered today ***); relevant findings: ***.
Independent interpretation of *** (study, for example the radiograph): my read shows *** (findings), performed and documented separately from any formal report.
Discussed management of *** directly with *** (name and specialty) by ***.
A discussion is an interactive exchange with a clinician outside your group: phone, in person, or a secure message that was answered. A message sent without a reply, a chart note, or a conversation with your own partner does not count. The exchange can be on a nearby day if it is part of this visit's decision.
Risk of the plan
Any one of these usually reaches moderate.
Prescription drug management: *** (started, adjusted, or continued after review of response, side effects, or the monitoring plan) *** for ***.
If the drug is sold over the counter at the strength you used, it is over the counter management (low risk), even on a prescription pad. Prescription strength (ibuprofen 800 mg, naproxen 500 mg) or a prescription only drug is prescription drug management.
Decision regarding elective major surgery without identified patient or procedure risk factors: ***, risks, benefits, and alternatives discussed.
Decision regarding minor surgery with identified patient or procedure risk factors: ***, because ***.
Minor and major follow the global period: 0 or 10 days is minor, 90 days is major. A decision about elective major surgery with risk factors, or any emergency major surgery, is high risk (level 5).
Phrases that support a level 5
High complexity. Two of the three columns at this level make the visit a 99215 or 99205.
Problems addressed
Addressed a chronic illness with severe exacerbation: ***, now *** (for example: acutely unstable, requiring steroids and possible admission).
Severe exacerbation means the chronic condition has become acutely unstable or threatening: a COPD flare needing systemic steroids and observation, decompensated heart failure, a diabetic with ketosis.
Addressed an acute illness or injury that poses a threat to life or bodily function: *** (problem).
Data reviewed
Independent interpretation of *** (study) and discussion of management with *** (other clinician), plus review of *** (records or results).
Risk of the plan
Any one of these usually reaches high.
Decision regarding major surgery in a patient with significant comorbidities: *** (procedure), *** (comorbidities).
Decision regarding emergency major surgery: *** (procedure), *** (indication).
Drug therapy requiring intensive monitoring for toxicity: *** (drug), monitored by *** (lab test and interval) for *** (the toxicity being watched).
Monitoring for adverse effects, not effectiveness, usually by lab, generally at least quarterly: methotrexate with blood counts and liver enzymes, lithium levels, clozapine neutrophil counts. Source: AMA E/M guidelines (
references).
Decision to hospitalize, or to de-escalate care given the severity of *** (condition).
Three add-ons beyond the level
Each of these adds credit on top of the visit level, and each has its own page with the exact sentence to add to your note.
- G2211, the add-on for ongoing longitudinal care, blocked only when a procedure is billed the same day.
- Consultation codes: Medicare does not pay them, some commercial payers do, and many hospital systems credit the consult wRVU regardless.
- Modifier 25, a separately identifiable visit on the day of a procedure.
These phrases follow the 2021 office and outpatient MDM framework and are for education only. Document only what is true for the encounter, and code only what your documentation supports.