What are the E/M code levels for office visits?

New patient codes 99202-99205 and established patient codes 99211-99215 are selected based on medical decision making (MDM) complexity or total time. 99202/99211 is straightforward, 99203/99213 is low, 99204/99214 is moderate, and 99205/99215 is high complexity. The 3-year rule determines new vs established status.

How do I determine the level of medical decision making?

MDM has three elements: 1) Number and complexity of problems addressed (minimal to high), 2) Amount and complexity of data reviewed/ordered (minimal to extensive), 3) Risk of complications, morbidity, or mortality (minimal to high). Two of three elements at a given level determines the MDM complexity.

What documentation supports a 99214 office visit?

99214 requires moderate MDM. Document: 1+ chronic illness with mild exacerbation OR 2+ chronic stable conditions OR 1 undiagnosed new problem with uncertain prognosis, PLUS moderate data (review of external records, discussion with external physician, or independent interpretation of tests), PLUS moderate risk (prescription drug management).

When should I use time-based billing instead of MDM?

Use time-based billing when total time spent on the encounter date (including pre-visit prep, face-to-face, and post-visit work) exceeds time thresholds for a code level AND time better reflects the clinical work than MDM. Time thresholds: 99213=20-29 min, 99214=30-39 min, 99215=40-54 min.

What are common E/M documentation errors that trigger audits?

Common errors include: upcoding without supporting documentation, cloned notes lacking individualization, missing required elements (history, exam, MDM), documenting more complexity than clinical situation warrants, inconsistent diagnoses between note and billing, and failing to document time for time-based billing.

E/M Coding Documentation Guide — Office Visit Billing Template

Administrative All Specialties Updated: 11/26/2025

The E/M Coding Documentation Guide helps physicians and medical coders understand evaluation and management documentation requirements for accurate billing. This comprehensive guide covers medical decision making (MDM) complexity levels, time-based billing documentation, new vs established patient criteria, and documentation requirements for each E/M code level (99202-99215). Includes practical examples of documentation that supports straightforward, low, moderate, and high complexity MDM. The guide addresses common documentation pitfalls, audit triggers, and strategies for appropriate code selection. Essential for primary care providers, specialists, hospitalists, and any clinician billing office/outpatient E/M services.

E/M Coding Documentation Guide

Medical Decision Making (MDM) Overview

MDM has three components. Two of three at a given level determines overall complexity.
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MDM Component 1: Problems Addressed

Level	Problems
Minimal	1 self-limited problem
Low	2+ self-limited OR 1 stable chronic OR 1 acute uncomplicated
Moderate	1+ chronic with mild exacerbation OR 2+ stable chronic OR 1 new problem with uncertain prognosis
High	1+ chronic with severe exacerbation OR 1 acute/chronic threatening life/function

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MDM Component 2: Data Reviewed

Level	Data Requirements
Minimal	Minimal or none
Limited	Review prior external notes OR each unique test ordered
Moderate	External notes from each source AND/OR independent test interpretation AND/OR external provider discussion
Extensive	All moderate elements AND obtaining history from someone other than patient

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MDM Component 3: Risk

Level	Risk Examples
Minimal	OTC drug management
Low	Prescription drug management
Moderate	Rx management with PDMP check, minor surgery decision
High	Drug requiring intensive monitoring, hospitalization decision

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Code Selection Summary

New Patient (99202-99205)

Code	MDM	Time
99202	Straightforward	15-29 min
99203	Low	30-44 min
99204	Moderate	45-59 min
99205	High	60-74 min

Established Patient (99211-99215)

Code	MDM	Time
99212	Straightforward	10-19 min
99213	Low	20-29 min
99214	Moderate	30-39 min
99215	High	40-54 min

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Documentation Checklist

99214 Requirements

[ ] Chronic illness with mild exacerbation OR 2+ stable chronic conditions
[ ] Moderate data (external records, independent interpretation, or provider discussion)
[ ] Moderate risk (prescription management)
[ ] Clinical reasoning documented

99215 Requirements

[ ] Chronic illness with severe exacerbation OR life-threatening condition
[ ] Extensive data review
[ ] High-risk decisions documented
[ ] Complex treatment plan