E/M office visit coding series: Quiz

If you’ve read the previous posts in this series, you should be able to select the correct level of service for each of these E/M office visits, based only on some short documentation from the assessment/plan. (Note: All visits in this quiz are with established patients.)

Read each line of documentation, and write down whether you think it describes a level 2, 3, 4, or 5 visit. Then check your work against the answer key below.

Assessment/plan documentation

1. Patient with depression. “Total Time spent caring for the patient today was 40 minutes. Total time includes time spent before the visit reviewing the chart, time spent seeing the patient, and time spent after the visit on documentation and prescribing medication.”

2. “HTN, poorly controlled, increase losartan to 100 mg.”

3. “DM, controlled, continue current medications … HTN, stable, continue metoprolol.”

4. “HTN, stable, continue amlodipine.”

5. “Viral URI, guaifenesin recommended.”

6. “Annual exam. Cellulitis, start cephalexin … shoulder injury … total time: 30 minutes. (time excludes annual exam).”

7. “Sinusitis, amoxicillin-potassium clavulanate prescribed … Knee strain, NSAIDS and ice recommended … Depression, stable, continue fluoxetine … Total time: 29 minutes.”

8. Patient with hip pain for last two weeks. “Greater trochanteric bursitis, hip bursal injection performed … Total time spent caring for the patient today was 20 minutes.  Total time includes time spent before the visit reviewing the chart, time spent seeing the patient, and time spent after the visit on documentation. Total time excludes procedure time.”

9. “Knee injury, x-ray ordered and interpreted by myself and it shows … Total time: 35 minutes. Total time includes time spent before the visit reviewing the chart, time spent seeing the patient, and time spent interpreting x-ray.”

10. “Diabetes, A1C not to goal, increase metformin … Total time: 30 minutes.”

11. “Diabetes, A1C not to goal, increase metformin … Total time: 25 minutes.”

12. “Multiple problems addressed. Total time: 70 minutes.”

Answer key

1. Established patient, 40 minutes total time = Level 5 visit.
2. Unstable chronic illness + medication management (Rx) = Level 4 visit.
3. Two stable chronic illnesses + Rx = Level 4 visit.
4. One stable chronic illness + Rx = Level 3 visit.
5. Uncomplicated acute illness + OTC recommendation = Level 3 visit.
6. One acute illness and one injury + Rx or 30 minutes total time = Level 4 visit plus preventive medicine visit billed together using modifier 25.
7. One acute illness + Rx, one uncomplicated injury, and one stable chronic illness + Rx or 29 minutes total time = Level 3 visit.
8. Total time excluding hip injection 20 minutes = Level 3 visit plus hip injection procedure billed together using modifier 25.
9. Total time 35 minutes = Level 4 visit.
10. Unstable chronic illness + Rx or 30 minutes total time = Level 4 visit.
11. Unstable chronic illness + Rx = Level 4 visit (in this case documenting total time does not reinforce a level 4 and may only confuse the issue).
12. Total time 70 minutes = Level 5 visit plus prolonged services (G2212 or 99417).

— Keith W. Millette, MD, FAAFP, RPH

Posted on Dec. 12, 2022