Quick Wins
Quick Wins: Phrases That Support a Level 4 or 5 Visit
The work is usually already in the room; the note just never says so. These are the exact phrases that put it in writing, organized by the rule each one satisfies. Copy, paste, fill in the brackets, and only ever for work you actually did.
Under the 2021 rules, the level is set by medical decision making: the problems you addressed, the data you reviewed, and the risk of your plan. You need two of those three at a level to support it. 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.
Phrases that support a level 4 (moderate complexity)
Problems addressed
Addressed two or more stable chronic conditions: [condition 1] and [condition 2], both reviewed and managed today.
Addressed one chronic illness with progression: [condition], now [worsening or not at goal], plan adjusted accordingly.
Addressed one acute illness with systemic symptoms: [problem] with [symptoms].
Data reviewed
Reviewed external records and prior results from [source]; relevant findings: [summary].
Independent interpretation of [study, e.g. the radiograph]: my read shows [findings], performed and documented separately from any formal report.
Discussed management of [issue] directly with [other clinician or specialty].
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] [medication] for [condition].
Decision for an elective minor procedure: [procedure], risks and alternatives discussed.
Any single phrase under risk, paired with the right problem or data above, supports a level 4. Prescription drug management alone is the most common path most providers miss.
Phrases that support a level 5 (high complexity)
Problems addressed
Addressed a chronic illness with severe exacerbation or progression: [condition], [severity and impact].
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], with monitoring for [toxicity].
Decision to hospitalize, or to de-escalate care given the severity of [condition].
The three highest-value plays
If you change three habits, change these. Each is worth real wRVUs and takes one or two lines to document.
G2211: add it on visits where you hold ongoing responsibility for the problem. It drops on ordinary procedure days with modifier 25; CMS allows narrow preventive exceptions such as the annual wellness visit.
What to do: append G2211 to the office visit. It is not separately payable when modifier 25 is on a same-day procedure, so use it on visits without a same-day procedure. CMS allows limited preventive service exceptions, such as the annual wellness visit or vaccine administration, when criteria are met.
This visit is part of my ongoing, longitudinal care for this patient.
Referred patient, no follow-up: code a consultation
What to do: code the consultation level instead of a new patient visit, where the payer recognizes consultation codes.
Seen at the request of [referring provider] for my opinion on [problem]. Findings and recommendations communicated back to [referring provider] in this report.
A procedure plus a real evaluation: add modifier 25
What to do: append modifier 25 to the E/M. It applies in either of two situations. One, the evaluation addressed a separate problem from the procedure (a different diagnosis), so the E/M and the procedure are coded separately. Two, the evaluation was for the same problem but went above and beyond the routine work the procedure itself already includes. Document which one applies.
A significant, separately identifiable evaluation and management service was performed today, above and beyond the work of [procedure]: [the separate problem and your assessment].
Check yourself in one click. Paste a de-identified note into the
AI E/M Assistant and it will show which of these three columns your documentation already supports.