Chapter 15 — Key Takeaways

What an E/M code measures

The cognitive work of the reporting professional — by medical decision making OR by total time on the date of the encounter.

Two roads. Either one. Never a blend. Select by whichever the documentation supports at the higher level.

Since 2021, history and examination DO NOT determine the level.

A medically appropriate history and/or examination is still required — appropriate is a clinical judgment, not a coding count. Nobody counts bullets anymore.

New vs. established

Not seen by this professional, or one of the exact same specialty and subspecialty in the same group, for any professional service, within three years → NEW (99202–99205). Otherwise ESTABLISHED (99211–99215).

99201 was deleted in 2021 — four new-patient levels, five established. Any professional service counts, including hospital and procedures. Three years to the day.

The 2021 rewrite, in five lines

1. History and exam out of level selection
2. 99201 deleted
3. MDM redefined with a published grid
4. Time redefined as total time on the date, non-face-to-face included, counseling dominance gone
5. New office prolonged services code

2023 extended the same framework to hospital, observation, consultations, ED, nursing facility, and home — Chapter 16.

MDM: three elements, two-of-three

Two of three elements must meet or exceed a level. The lowest element does NOT cap the level. It simply does not participate.

Element 1 — Problems addressed

Addressed = evaluated or treated, including options considered and declined. Notation of a problem managed by someone else, without additional assessment or care coordination, is NOT addressed.

"STABLE" MEANS AT TREATMENT GOAL — NOT "UNCHANGED."

An A1c of 10.2 for two years is not stable. The poorly controlled patient scores higher, because managing them is harder work.

Moderate, most often: 2 or more stable chronic illnesses · 1 chronic illness with exacerbation or progression · 1 undiagnosed new problem with uncertain prognosis · 1 acute illness with systemic symptoms · 1 acute complicated injury.

Element 2 — Data

Cat. 1 unique tests / unique external notes / independent historian · Cat. 2 independent interpretation (not separately reported) · Cat. 3 discussion with an external professional (not separately reported)

The four counting rules that decide disputes:

• A unique test = a CPT code. A panel is ONE test.
• Ordering and reviewing the same test is ONE item. Review is included in the order.
• "External" = different group, or different specialty/subspecialty — not merely a different person.
• Cat. 3 requires an interactive discussion. A letter sent is not a discussion.

Bill it with modifier 26 or count it under Category 2 — not both.

Element 3 — Risk

Includes options considered but NOT selected — if documented.

Prescription drug management is a DECISION, not a list. "Metformin 1000 mg BID" in the medication list = inventory. "Diabetes at goal — continue metformin 1000 mg BID" in the plan = management.

Time

Counts: the reporting professional's own time on that calendar date — prep, history, exam, counseling, ordering, documenting, care coordination not separately reported.

Does NOT count: clinical staff time · other dates · separately reported services · travel.

Meet the minimum. No rounding. 29 minutes established is a 99213.

Time never caps an MDM level. Moderate MDM with 26 documented minutes is still a 99214.

Prolonged services

99417 — each additional complete 15 minutes beyond the highest level only (99205/99215). Add-on code: Chapter 13 §13.7's rules apply.

Medicare uses G2212, with a different starting threshold. A practice sending 99417 to Medicare has it backwards.

Split/shared and incident-to

Split/shared — facility setting, physician + NPP same group, reported by whoever performed the substantive portion. That definition has changed more than once — verify it against current CMS guidance.

Incident-to — office setting, billed under the physician's NPI at 100% instead of 85%. Requires: established patient · established plan of care · NO NEW PROBLEMS · direct supervision (in the office suite).

A new problem breaks incident-to — silently. Establishing a default for all established patients generates an overpayment on every visit where someone brings up something new, with no denial, no edit, and no phone call.

Documentation that survives an audit

1. Each problem named individually, with a status and a plan
2. Decisions visible as decisions — in the plan, not the list
3. Orders state their reason
4. Considered-and-rejected options written down
5. Time stated as a total, on the date, by the reporting professional
6. The note is about this patient on this day — copy-forward destroys the credibility of everything around it

Key terms

E/M · new / established patient · three-year rule · medical decision making · problems addressed · stable chronic illness · data reviewed and analyzed · unique test · independent interpretation · risk · prescription drug management · total time on the date of the encounter · prolonged services · split/shared · substantive portion · incident-to

Monday morning

You should be able to:

• Score all three MDM elements from an assessment and apply two-of-three without hesitating.
• Say what "stable" means and correct the person who says "unchanged."
• Count data without inflating panels or double-counting orders.
• Tell a medication list from prescription drug management at a glance.
• Choose between MDM and time, correctly, on the same encounter.
• Say what breaks incident-to and what it costs.
• Sum documented time by provider by date, and check it against the day.

The Encounter — Account 10-4471, March 14, is a 99214.

Problems MODERATE (three stable chronic illnesses addressed — and, independently, one undiagnosed new problem with uncertain prognosis) · Data LIMITED (two unique tests ordered; the lipid panel is one test) · Risk MODERATE (three medications continued with documented decisions).

Two of three at moderate. The low data element changes nothing — this is the two-of-three rule in its purest illustration.

Time is unavailable: the note says "Time was not used for level selection on this encounter."

And the same three sentences in that assessment are doing three jobs at once — the moderate problems element, the moderate risk element, and Chapter 14's evidence that the E/M was separately identifiable from the injection. Delete them and the level falls to 99213 and modifier 25 becomes unsupportable in the same stroke.