• Savvy Coder

    E/M Rules for Office Visits: What Level of Medical Decision-Making?

    By David B. Glasser, MD, Academy Secretary for Federal Affairs; Michael X. Repka, MD, MBA, Academy Medical Director for Governmental Affairs; and Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement

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    Under the E/M rules that went into effect on Jan. 1, 2021, the complexity of medical decision-making (MDM) is used to determine what level of E/M code you can use for an office visit. Make sure that your documentation validates the MDM level that you bill.

    Four levels of medical decision-making. The overall complexity level of MDM can be straightforward or of low, moderate, or high complexity. To determine this overall level of MDM, you first look at three components (see next paragraphs) and determine which level of MDM complexity each of them would support (see “E/M Resources”). If at least two components indicate the same level of MDM, then that would determine the overall level of MDM. If the three components point to three different levels of MDM, then the mid­dle one would determine the overall level of MDM.

    Component 1: The number and/or complexity of problems addressed at the patient encounter.

    Component 2: The amount and/or complexity of data to be reviewed and analyzed.

    Component 3: The risk of complica­tions and/or morbidity or mortality of patient management.

    Which E/M codes can you bill for the office visit? The E/M codes that you can use depend on the complexity level of MDM:

    • Straightforward: Use codes 99202 or 99212 for new and established patients, respectively.
    • Low complexity: 99203 or 99213.
    • Moderate complexity: 99204 or 99214.
    • High complexity: 99205 or 99215.

    E/M Resources

    Conquering New E/M Documentation Guidelines for Ophthalmology includes charts that will show what documentation is required to support the different levels of MDM. It combines a narrated online tutorial with an accompanying workbook. Review the step-by-step instructions, clinical examples, and worksheets, and then pass the exam section to earn an elec­tronic certification of completion. Buy it at aao.org/codingproducts.

    For further reading, including links to four earlier EyeNet articles on the new E/M documentation guidelines, visit aao.org/em.

    Tackle These Three Cases

    Based on the documentation for each of the exams below, determine which E/M codes to bill.

    Case A: An infant with dacryosteno­sis. A pediatrician referred a patient to a pediatric ophthalmologist.

    Impression. Intermittent, bilateral, congenital nasolacrimal duct obstruc­tion of a 9-month-old.

    Plan. Lacrimal massage, twice a day. Antibiotic drops three times a day for three days to improve mucopurulent discharge. Discussed possible need for surgery, but not yet since there are some “clear” days with no symptoms.

    Case B: A toddler’s swollen eyelid. A 3-year-old presented with a red, swollen left upper lid (LUL), with increasing severity over the previous two days. He had an associated upper respiratory infection.

    Impression: Preseptal cellulitis LUL.

    Plan: Considered ordering comput­ed tomography or magnetic resonance imaging of the orbit, but deferred that order since able to see full ocular motility. Discussion with pediatrician about Rocephin (ceftriaxone sodium) injection. Prescribed oral antibiotics for 10 days. Instructed patient’s mother to call if increased fever or swelling over the subsequent 24 hours.

    Case C: A patient with shingles. A patient had shingles on the right side of her face and, ultimately, in her right eye. She had severe pain and photopho­bia in the right eye.

    Impression: Zoster in the right eye.

    Plan: Prescription drug management with acyclovir and topical steroids. Follow-up in one week or sooner. Phone conversation about findings and treatment with primary care physician.

    Which E/M code would you bill for each of these exams? See answers below.

    The Exam Establishing a Need for Cataract Surgery

    A patient is eager to undergo cataract surgery in the right eye, followed shortly by cataract surgery in the left eye. Which E/M code would you use for the initial exam?

    Component 1—problems addressed: This would fall under the category of “one or more chronic illnesses with exacerbation, progression, or side effects of treatment.” By consulting the chart in the Conquering New E/M workbook (see “E/M Resources”), you will know that this represents a moderate-level problem and that it supports a moderate-complexity level of MDM.

    Component 2—data reviewed: No data were reviewed. This doesn’t support any level of MDM.

    Component 3—risk: Does this fall within the category of “Decision regarding elective major surgery without identified patient or procedure risk factors”? If it does, then it would be considered a moderate level of risk and would support a moderate-complexity level of MDM.

    Based on the three components, this documentation would support a moderate-complexity level of MDM, and you could bill E/M code 99204 for a new patient or 99214 for an established patient.

    What patient or procedure risk factors would make the decision for cataract surgery high risk? Deciding whether to perform cataract surgery would involve a high level of risk and would involve a high-complexi­ty level of MDM if it fell within this category: “Decision regarding elective major surgery with identified patient or procedure risk factors.” But what risk factors would be sufficient? Cataract surgery for a patient with high myo­pia? Cataract surgery combined with releasing multiple adhesions between the lens and iris, with the potential impact on case management noted in the assessment and/or plan? Active asthma at risk of exacerbation with anesthesia/oxygen supplementation? Ultimately it is the surgeon’s choice. If a review of the three components shows that the exam involved high-complexity MDM, you could bill 99205 or 99215 for the exam.

    Further documentation needed. As always, your docu­mentation of the exam should show that you met the requirements for the level of MDM complexity that you are billing. Furthermore, make sure that your documen­tation meets the payer’s requirements detailed in “Fact Sheet for Documenting the Need for Cataract Surgery” (January 2021, EyeNet).


    Here are the answers for this month’s E/M challenge.

    Case A: Component 1—problems addressed: One acute, uncomplicated illness or injury (low-level problem; supports a low-complexity level of MDM). Component 2—data reviewed: An independent historian, such as a parent, was needed (limited level of data review; supports a straightforward level of MDM). Component 3—risk: Prescription drug management (mod­erate level of risk; supports a moderate-complexity level of MDM). The documentation would support a low-complexity level of MDM, and you could bill E/M codes 99203 or 99213.

    Case B: Component 1—problems addressed: One undiagnosed new prob­lem with uncertain prognosis (moderate-level problem; moderate-com­plexity MDM). Component 2—data reviewed: Independent historian and discussion of management with a pediatrician (moderate level of data review; moderate-complexity MDM). Component 3—risk: Prescription drug management (moderate level of risk; moderate-complexity MDM). The documentation would support a moderate-complexity level of MDM, and you could bill E/M codes 99204 or 99214.

    Case C: Component 1—problems addressed: Chronic illnesses with severe exacerbation, progression, or side effects of treatment (high-level prob­lem; high-complexity MDM). Component 2—data reviewed: Discussion of management with external physician (moderate level of data review; mod­erate-complexity MDM). Component 3—risk: Prescription drug manage­ment (moderate level of risk; moderate-complexity MDM). The documen­tation would support a moderate-complexity level of MDM, and you could bill E/M codes 99204 or 99214.