• Three common reasons for level 5 E/M office visits in primary care

    Keith W. Millette, MD, FAAFP, RPH

    If you’ve read the January/February issue of FPM, you know how to identify level 4 office visits under the new evaluation and management (E/M) guidelines and avoid losing money by under-coding them. But what about level 5 visits?

    While not as common, level 5 visits do occur in primary care, and under-coding them can also have serious financial ramifications. To quickly identify and correctly code most level 5 office visits, keep in mind these three common reasons for level 5 work:

    Reason No. 1: Time

    The new guidelines allow coding of outpatient E/M office visits based solely on either total time on the date of service or medical decision making (MDM). Many level 5 office visits billed by family physicians will be based on time. If your total time is at least 40 minutes for an established patient or 60 minutes for a new patient, code that visit as a level 5.

    Remember that total time includes all time spent caring for that patient on the day of the encounter. That means you count your prep time reviewing the chart before the visit, your face-to-face time during the visit, and the time you spend after the visit (as long as it occurs before midnight) reviewing studies, making phone calls, documenting your note, etc. (See these tips for tracking time.)

    You must document your total time in the note. Because patients may read your notes, consider writing: “Total time was XX minutes. That includes chart review before the visit, the actual patient visit, and time spent on documentation after the visit.” This helps patients understand that you spend a lot of time behind the scenes caring for them, and it may even prevent confused patients from falsely accusing you of fraud (e.g., “He only spent 20 minutes with me, not the 40 minutes he listed in his note”). Time spent on separately billed procedures done during an E/M visit does not count toward total time, so adding a statement such as “Time excludes procedure” is also helpful.

    Reason No. 2: Pre-op visits for major surgery

    To code a level 5 office visit using MDM you need at least two out of these three elements: high complexity problems, high risk, or extensive data review. Pre-op visits before elective major surgery in patients who have risk factors or require labs, X-rays, or electrocardiograms (ECGs) for evaluation/preoperative clearance often check these boxes.

    There are two types of risk you can consider when it comes to pre-op visits: procedure risk and patient risk. Major surgery involves high procedure risk, including general anesthesia and the procedure itself (e.g., coronary artery bypass, total hip replacement, and abdominal surgery). Patient risk factors include morbid obesity, heart disease, diabetes, lung disease, etc. It is important to document both the patient risk factors and the procedure risk in your note.

    The data portion of MDM is split into three categories:

    1. Tests, documents, or independent historian(s); any combination of three from the following:

    • Review of prior external note(s) from each unique source,
    • Review of the result(s) of each unique test,
    • Ordering of each unique test,
    • Assessment requiring independent historian(s).

    2. Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported).

    3. Discussion of management or test interpretation with an external physician or other qualified health professional/appropriate source (not separately reported).

    A visit must include at least two out of those three categories to qualify as level 5 “data” work. For level 5 pre-op visits, this commonly involves ordering/reviewing a minimum of three tests (e.g., labs, ECG, and chest X-ray) and interpreting at least one study (e.g., ECG or X-ray). To get credit for interpretation it must be clear in the note that you evaluated the study (e.g., “I personally evaluated the chest X-ray and it shows … ”) and did not just look at the report. Remember, if your health system is billing separately for the interpretation, you cannot count it toward your E/M visit level (for more tips on counting MDM data, click here).

    For practical purposes, the minimum criteria for coding level 5 pre-ops would look something like this as a simple equation: Level 5 pre-op = major surgery + risk factors + order/review three tests + interpret one study.

    Reason No. 3: Very sick patients who require work up and/or admission decision

    Very sick patients often require level 5 work if they have a high complexity problem such as acute respiratory distress, depression with suicidal ideation, or any new life-threatening illness or severe exacerbation of an existing chronic illness. It is common for these visits to qualify as high risk or require extensive data review, thereby pushing them into level 5 territory. Examples include the following:

    1. Seeing a very sick patient (such as one with severe exacerbation or progression of their chronic condition, or side effects of treatment of their chronic condition) in the office who requires hospital admission (and you are not doing the admitting yourself) or requires you to contemplate admission (make sure to document your thought process in the note). This combines a high-complexity problem (or problems) with high risk.

    2. Seeing a very sick patient (such as one with an acute or chronic condition that poses a threat to life or bodily function) who requires an office work up that qualifies as level 5 data review (e.g., ordering/reviewing a minimum of three tests and interpreting one study). This combines a high complexity problem (or problems) with extensive data.


    To summarize, here are the three common reasons to code a level 5 office visit:

    Total time ≥ 40 minutes for established patients; ≥ 60 minutes for new patients
    Pre-op visit Major surgery with risk factors plus 3 tests plus interpretation of 1 study
    Very sick patient Admission decision or work up — 3 tests plus interpretation of 1 study

    These are only a few useful examples of level 5 work. Less common scenarios may also qualify, such as visits that include decisions to de-escalate care or initiate do-not-resuscitate orders, decisions about emergency major surgery, and decisions about the use of drugs that require intensive monitoring. Referring to a coding template can be helpful for those scenarios. But for the three types of visits outlined above, you should not be afraid to think level 5 if your documentation supports it.

    — Keith W. Millette, MD, FAAFP, RPH, is a family physician in Grand Forks, N.D.

    Posted on Feb 11, 2021 by FPM Editors

    Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use.