We asked a coder in her third week to level a note: a 58-year-old with hypertension and type 2 diabetes, both "stable," medications continued, A1c ordered, follow-up in three months. She chose 99213. Two stable chronic illnesses, she said, is moderate for problems, but the physician did not change anything, so the risk is low, and low plus moderate is 99213. She had two of the three pieces right and the wrong answer. Continuing a prescription medication after evaluating it is prescription drug management, which is moderate risk. The visit was a 99214.
The 99213 vs 99214 decision is the most consequential routine choice in office coding. In most practices those two codes account for the majority of visits, and the payment difference between them is roughly $35 to $45 under Medicare and often more under commercial contracts. A coder or a physician who systematically picks the wrong one is moving tens of thousands of dollars a year in one direction or the other, and both directions are a problem.
Since January 1, 2021, office visit levels for established patients (99212 to 99215) and new patients (99202 to 99205) are chosen by medical decision making (MDM) or by total time on the date of the encounter. History and exam are no longer scored. A glossary line: MDM is the cognitive work of the visit, measured on three elements, and the level is the highest one reached by two of the three.
Key takeaways
- The level is set by two of three MDM elements (problems, data, risk) or by total time; teach both, but teach MDM first because most notes support MDM more reliably than time.
- The definitions decide the level: "stable" means at treatment goal, "prescription drug management" includes continuing a drug after evaluation, and "independent historian" has a specific meaning.
- 99213 is low MDM; 99214 is moderate; the commonest error in each direction is misreading whether a chronic illness is stable.
- Time thresholds for 2021 onward are 20 minutes for 99213 and 30 minutes for 99214, counting all the physician's time on the date, not just face-to-face.
- Teach with real de-identified notes from the practice, not textbook vignettes, and audit new coders weekly for the first two months.
The three elements, in the words that matter
| Element | Low (99213) | Moderate (99214) |
|---|---|---|
| Number and complexity of problems addressed | Two or more self-limited or minor problems; or one stable chronic illness; or one acute, uncomplicated illness or injury | One or more chronic illnesses with exacerbation, progression or side effects of treatment; or two or more stable chronic illnesses; or one undiagnosed new problem with uncertain prognosis; or one acute illness with systemic symptoms; or one acute complicated injury |
| Amount and complexity of data reviewed and analyzed | Limited: at least two from (review of prior external notes from each unique source, review of each unique test result, ordering of each unique test) or assessment requiring an independent historian | Moderate: at least one of three categories: (1) any three from the list above including independent historian; (2) independent interpretation of a test performed by another physician; (3) discussion of management or test interpretation with an external physician or appropriate source |
| Risk of complications and/or morbidity of patient management | Low risk from additional diagnostic testing or treatment (over-the-counter drugs, minor surgery with no identified risk factors, physical therapy) | Moderate risk: prescription drug management; decision regarding minor surgery with identified risk factors; decision regarding elective major surgery without risk factors; diagnosis or treatment significantly limited by social determinants of health |
Three definitions do most of the work, and we drill them until the coder can recite them.
Stable. CPT defines a stable chronic illness as one at its treatment goal. A patient with hypertension whose blood pressure is 158/94 with a goal under 140/90 is not stable, even if the note says "stable" and the medication is unchanged. That patient has a chronic illness not at goal, which counts as exacerbation or progression, and the problem element is moderate on that alone.
Prescription drug management. This includes prescribing a new drug, changing a dose, stopping a drug, and continuing a drug after evaluating its effect. The decision to continue is management. It has to be documented as a decision ("continue lisinopril 20 mg, BP at goal"), not as a med list that was carried forward.
Independent historian. A parent, spouse, caregiver or other person who provides history because the patient cannot (age, dementia, altered state) or because a confirmatory history is judged necessary. A spouse who happens to be in the room and adds a comment is not an independent historian.
Six worked cases
- Established patient, one stable chronic illness, no tests, medication continued. Problems: low (one stable chronic illness). Data: minimal or none. Risk: moderate (prescription drug management). Two of three: low and moderate reach low twice? No. The level is the highest reached by at least two elements. Low is reached by problems; moderate is reached by risk only. Two elements at low or higher: yes, problems and risk. Two at moderate: no. Result: 99213.
- Two stable chronic illnesses, A1c ordered, medications continued. Problems: moderate (two stable chronic illnesses). Data: limited (one test ordered; needs two items for limited, so this is minimal). Risk: moderate (prescription drug management). Two at moderate: problems and risk. Result: 99214. This is the case the new coder missed.
- Acute uncomplicated illness (viral URI), OTC recommendations, no tests. Problems: low. Data: none. Risk: low (OTC drugs). Result: 99213.
- Acute illness with systemic symptoms (fever, pyelonephritis suspected), urinalysis and culture ordered, antibiotic prescribed. Problems: moderate. Data: limited (two tests ordered). Risk: moderate (prescription). Result: 99214.
- Chronic illness not at goal (hypertension 158/94), dose increased, BMP ordered, prior cardiology note reviewed. Problems: moderate (not stable). Data: moderate (three items: test ordered, external note reviewed, and a second test or result). Risk: moderate. Result: 99214, and if the physician also documented a decision about a higher-risk drug or the patient had a second uncontrolled condition, the note should be checked for 99215.
- Two self-limited problems (contact dermatitis and a minor sprain), topical OTC and ice. Problems: low. Data: none. Risk: low. Result: 99213.
We give trainees ten real de-identified notes from the practice each week, have them level each with the element reached for all three, and review the answers together. The point is not the answer; it is the sentence in the note that supports each element.
Time, and when to use it
Total time on the date of service includes preparing to see the patient, obtaining history, performing the exam, counseling, ordering, documenting and communicating with other professionals, whether or not face-to-face, but not staff time and not time on other days. The 2021 thresholds are 20 to 29 minutes for 99213 and 30 to 39 minutes for 99214 (CPT revised the wording in 2023 so that the stated minutes must be met or exceeded). Time is the right method when a visit is long but simple: a 35-minute counseling visit about a single stable problem is a 99214 on time and a 99213 on MDM. The note must state the total time and, ideally, what it was spent on. "Total time 35 minutes" with no activities listed is weak in an audit.
The mistakes we see in audits
Under-coding: calling a chronic illness stable because the plan did not change, missing prescription drug management when drugs are continued, and not counting external records reviewed. Over-coding: counting the same test twice (ordered and then reviewed at the same visit counts once), counting a med list as prescription management with no documented decision, treating every chronic illness as "with exacerbation" without a finding to support it, and using time without a time statement. The last one, honestly, is the most common finding in the practices we audit, and it is fixed by a single template field.
Coders learn this fastest with real charts and a safe place to be wrong. Our live online RCM courses teach E/M leveling this way, and the Revelrex EHR training environment lets trainees level and bill practice encounters without touching a live system.
Questions we hear
Does a new patient level differently?
The MDM table is the same for 99202 to 99205, and the time thresholds are higher (30 minutes for 99203, 45 for 99204). New patient status is about whether the patient has received professional services from the physician or another physician of the same specialty in the group within three years.
Can we count the physician's review of labs she ordered at the last visit?
No. A test ordered at a visit is counted at that visit, including the expected review of the result. Reviewing it at the next visit does not count again. Tests ordered by someone else and reviewed at this visit do count.
Should the physician or the coder pick the level?
The physician is responsible for the level; the coder verifies that the note supports it. In practices where coders level, the physician still signs. Either way, the training is the same, and we recommend physicians sit in on the first few weekly reviews.
What to do this week
- Pull ten de-identified 99213 and ten 99214 notes from the last month and have each coder level them blind, recording the element reached for problems, data and risk.
- Compare the results with the billed codes and discuss every disagreement using the CPT definitions of stable, prescription drug management and independent historian.
- Add a total time field with an activities list to the office visit template.
- Post the two-column MDM table above at each coding workstation.
- Schedule weekly ten-note reviews for the next eight weeks for any coder with under a year of E/M experience.
