Coding Level 4 Office Visits Using the New E/M Guidelines


Determining whether the visit you've just finished should be coded as a level 4 could be as simple as asking yourself three questions.

Fam Pract Manag. 2021 Jan-Feb;28(1):27-33.

Author disclosure: no relevant financial affiliations disclosed.

Performing level 4 evaluation and management (E/M) outpatient visits but coding them as level 3 visits is a costly mistake for family physicians. It can result in $30,000 or more in lost revenue in a year, depending on practice volume. Some doctors choose to report a level 3 instead of a level 4 because of fear of over-coding.1 Some do level 4 work but their documentation is lacking and doesn't support a level 4 code. But the most common reason I've seen for under-coding level 4 visits is that the coding criteria are complex and time-consuming.

“Coding is complicated and boring,” I often hear physicians say. “I have better things to do, like take care of my patients.”

New rules for coding and documenting outpatient E/M office visits should simplify things, clear up confusion, and help you code more confidently and accurately.

The rules, which took effect Jan. 1, are the most significant changes to E/M coding since 1997 (for more details, see “Countdown to the E/M Coding Changes” in the September/October 2020 issue of FPM). Coding for outpatient E/M office visits is now based solely on either the level of medical decision making (MDM) required or the total time you spend on the visit on the date of service. (See “E/M coding changes series.”) The history and exam components are no longer used for coding purposes. (Note: these changes apply only to regular office visits and not to nursing home or hospital E/M visits.)

The 2021 E/M coding changes should help ensure you're not leaving money on the table, especially when it comes to coding level 4 visits, which is not as straightforward as coding other levels.


  • Doing level 4 evaluation and management (E/M) work but coding it as a level 3 office visit is a common mistake that can cost a family physician thousands of dollars each year.

  • Rule changes that eliminated the history and exam portions from coding requirements should make it easier to identify level 4 office visits and code them for appropriate reimbursement.

  • Answering three basic questions can help you identify whether you've performed a level 4 visit.



These are the basic parameters for coding a level 4 visit based on total time or MDM under the new rules.

Total time includes all time the physician or other qualified health professional (QHP) spends on that patient on the day of the encounter. This includes time spent reviewing the patient's chart before the visit, face-to-face time during


Dr. Millette is a family physician practicing at Altru Family Medicine Center in Grand Forks, N.D. He has been teaching coding to physicians for almost 20 years.

Author disclosure: no relevant financial affiliations disclosed.


1. Hill E. How to get all the 99214s you deserve. Fam Pract Manag. 2003;10(9):31–36.

2. Marting R. 99213 or 99214? Three tips for navigating the coding conundrum. Fam Pract Manag. 2018;25(4):5–10.


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