E&M Coding Optimization — 99213 vs 99214 vs 99215

The 2021 E&M Revolution

Before 2021, E&M level selection required providers to document specific elements of history (HPI, ROS, PFSH) and physical exam (body systems and areas). This led to template-driven documentation bloat and frequent undercoding because providers couldn't remember which exam bullet points were needed.

The current guidelines eliminated these requirements entirely. Now, E&M level is determined by either the level of Medical Decision Making (MDM) or total time spent on the encounter (including non-face-to-face time on the date of service). Most practices use MDM as the primary method.

Medical Decision Making: The Three Elements

MDM is evaluated across three elements. You need to meet or exceed the threshold for at least two of the three elements to qualify for a given code level.

• Number and complexity of problems addressed — how many problems you're managing and how complex they are (self-limited, chronic stable, chronic worsening, new problem with workup, etc.)
• Amount and complexity of data reviewed — labs, imaging, external records, discussions with other providers, independent interpretation of tests
• Risk of complications, morbidity, or mortality — prescription drug management, decisions about surgery, hospitalization risk, etc.

99213 vs 99214: Where the Money Lives

The gap between 99213 ($92) and 99214 ($130) is about $38 per visit. For a provider seeing 20 patients per day, shifting just 3 visits per day from 99213 to 99214 (where documentation supports it) adds over $28,000 per year.

• 99213 (Low MDM) — 1-2 self-limited or minor problems; minimal data review; low risk (OTC drugs, minor surgery with no risk factors)
• 99214 (Moderate MDM) — 1+ chronic conditions with mild exacerbation, or 2+ chronic stable conditions, or new problem requiring additional workup; moderate data (ordering/reviewing tests, reviewing external records); moderate risk (prescription drug management, decisions about minor surgery with risk factors)
• 99215 (High MDM) — 1+ chronic conditions with severe exacerbation, or 1+ acute/chronic condition posing threat to life/function; extensive data (independent interpretation, discussion with external physician); high risk (drug therapy requiring intensive monitoring, decisions about hospitalization, DNR decisions)

Time-Based Coding

Since 2021, you can select E&M level based on total time spent on the date of encounter. This includes face-to-face time, chart review, ordering, care coordination, and documentation — all on the date of service.

• 99213 — 20-29 minutes total time
• 99214 — 30-39 minutes total time
• 99215 — 40-54 minutes total time
• 99417 (prolonged services) — each additional 15 minutes beyond 99215 threshold

Documentation Strategies That Support Higher Coding

Better coding starts with better documentation habits. The goal isn't to upcode — it's to accurately capture the complexity of the care you're already providing.

• Document every problem addressed, not just the chief complaint. If you refill a blood pressure medication, adjust diabetes management, and discuss an anxiety concern — that's 3 problems, not 1
• Explicitly state when you review labs, imaging, or external records. A simple note like "Reviewed 12/15 CMP — creatinine stable at 1.2" satisfies the data element
• Document your decision-making rationale. "Continuing metoprolol for rate control, monitoring for bradycardia" demonstrates prescription drug management and risk
• Use assessment and plan sections that mirror the number of problems. If you addressed 4 problems, your A&P should have 4 distinct items
• Record total time when it supports a higher code than MDM alone

Common Undercoding Patterns

After analyzing millions of Medicare claims, clear undercoding patterns emerge across specialties. Understanding these patterns helps identify where your practice may be leaving revenue behind.

• The "99213 default" — providers reflexively select 99213 for all follow-up visits regardless of complexity. This is the single largest revenue leak.
• Ignoring data review — reviewing a specialist's note, hospital discharge summary, or outside imaging counts toward MDM but is often undocumented
• Single-problem thinking — documenting only the primary complaint even when multiple problems were managed during the visit
• Fear of audit — providers undercode as a "safety margin" against audits. Modern audit standards under the 2021 guidelines actually make higher coding easier to defend
• Not using time-based coding — for visits that are legitimately time-intensive but have straightforward MDM

Audit-Proof Your Documentation

The best defense against audits is clean, specific documentation that clearly supports the code selected. Under the 2021 guidelines, auditors look at MDM elements (problems, data, risk) or documented time — not history and exam requirements.

Focus your documentation on the assessment and plan. Each problem should have a clear assessment (what's happening) and plan (what you're doing about it). Include the rationale for your decisions. If you reviewed data, say what you reviewed and what it showed. If there's risk, identify it specifically.