As of Jan. 1, physicians and other qualified health care professionals (QHPs) can code outpatient evaluation and management (E/M) office visits based solely on medical decision making (MDM) or total time.
The new rules should make it easier to avoid under-coding level 4 visits — a common and costly mistake. In fact, most level 4 visits can now be identified by asking just three questions:
1. Was your total time between 30 and 39 minutes for an established patient, or between 45 and 59 minutes for a new patient? If so, then you're done. Code it as a level 4 using total time.
2. Did you see the patient for a level 4 problem and either order/review level 4 data or manage level 4 risk? If so, then code it as a level 4 using MDM. (See the updated MDM requirements.)
3. Did you order/review level 4 data and manage level 4 risk? If so, code it as a level 4 using MDM.
Furthermore, ordering labs, x-rays, electrocardiograms (ECG), and medications often signals level 4 work. So, for an even more simplified rubric that works in almost as many scenarios, keep Question 1 above and substitute these for Questions 2 and 3:
2. Did you see the patient for a level 4 problem and either prescribe a medication, interpret an x-ray (or ECG), or order/review three tests?
3. Did you prescribe a medication and either interpret an x-ray (or ECG) or order/review three tests?
Read the full article in FPM: “Coding Level 4 Office Visits Using the New E/M Guidelines.”
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