E/M office visit coding series: How to code visits in one or two questions

The 2021 rules for coding problem-oriented E/M office visits allow coding based solely on total time personally spent by the physician or on medical decision making (MDM). These changes create a big opportunity to shorten our documentation, focus on pertinent history, and produce more concise, useful notes. They also allow us to code more quickly and accurately.

FPM has published extensive information about the 2021 changes, including my four-step system for coding office visits. This series of blog posts is intended to consolidate some of that information into short, quick tutorials that can be given during a department meeting, reviewed as an email, or shared with your partners.

How to code many office visits in one or two questions

A previous Getting Paid post explained how to code E/M office visits in four steps. But often it can be an even shorter process. These two questions can guide you through the coding of many visits:

1. Did you spend 30 minutes (for an established patient) or more of total time on the visit that day? If you did, and you believe the time spent accurately credits you for the amount of work you did (30-39 minutes for established patients = Level 4 visit, 40 or more minutes = Level 5 visit), then you can document your total time and you are done coding. If you spent less than 30 minutes or believe your medical decision making would give you credit for a higher level visit, go to Question 2.

2. Did you address a level 3 or level 4 problem* and perform medication management? You did? Then you can level the visit using MDM based on the problem level. If you recommend an over-the-counter medicine or prescribe/adjust a prescription medication (i.e., prescription drug management) for a level-3 problem or problems, then it’s at least a level-3 visit. (The visit level could be higher depending on the data you reviewed, but if level 3 accurately reflects the work you did, then the problems and medication management are all you need for coding purposes.) If you perform prescription drug management for a level-4 problem or problems, then it’s a level-4 visit.

A large percentage of most physicians’ office visits fall into these two parameters. For those that don’t, see the full four-step process. Future blog posts in this series will provide tips for time-based coding, further explain how identifying the level of the patient’s problems can help you quickly code based on MDM, and show how a brief sentence of documentation in the patient’s assessment and plan is all you need to code most E/M office visits under the new rules.

— Keith W. Millette, MD, FAAFP, RPH

*As outlined by the American Medical Association’s medical decision making guide: Table 2 – CPT E/M office revisions level of medical decision making (MDM). American Medical Association. 2019. Accessed Oct. 19, 2022. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Posted on Oct. 24, 2022