Since the office-visit overhaul, evaluation and management levels rest on two alternative pillars: medical decision-making or total time on the date of the encounter. Coders may use whichever supports the level — and that choice, made visit by visit, is where accuracy and revenue quietly diverge. Here’s how to make it deliberately.
The two paths, briefly
MDM is scored across three elements — the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications or morbidity of patient management. Two of the three elements must meet or exceed the level being reported.
Total time counts the practitioner’s own time on the encounter date: face-to-face plus same-day non-face-to-face work such as reviewing records before the visit, documenting afterward, ordering tests, and coordinating care. It does not include clinical staff time, and it does not include time on separately billed services.
The same visit can level differently down each path — which is precisely why the choice matters.
When time usually wins
- Counseling-heavy visits. A stable problem discussed at length — contraception options, lifestyle counseling, a long goals-of-care conversation — may score modest MDM but substantial time.
- Coordination-heavy days. Visits wrapped in record review, calls to specialists, and extended documentation add real minutes that MDM never sees.
- The catch: the record must state total time and, ideally, sketch what filled it. A bare minute count invites audit skepticism; “35 minutes total time including pre-visit record review and post-visit care coordination” holds up.
When MDM usually wins
- Efficient complexity. An experienced clinician can address multiple chronic conditions with prescription management — solidly moderate MDM — in fifteen minutes. Time would undersell it badly.
- High-risk decisions made quickly. Decisions about hospitalization, drug therapy requiring intensive monitoring, or surgery carry MDM weight regardless of how long the conversation took.
- The catch: MDM lives or dies on documented problems addressed, not merely listed. A problem list is not decision-making; the note must show assessment and management of each condition counted.
The failure patterns auditors find
- Defaulting to one path for every visit. Coders who always use MDM leave counseling visits underleveled; providers who always document time inflate levels on quick complex visits and draw scrutiny.
- Double-counting data. Tests separately billed by the practice can’t also count as data reviewed in MDM.
- Time math errors. Including staff time, spreading time across dates, or counting time spent on a procedure billed separately.
- Copy-forward MDM. Identical assessment language across visits undermines the claim that problems were freshly addressed.
Building the habit
Teach coders and providers to make the comparison explicit on borderline visits: level it both ways, take the supported higher path, and make sure the documentation for that path is airtight. Audit a monthly sample specifically for path selection — not just “is the level right” but “was the better-supported path chosen.” Most organizations that run this audit find systematic underleveling on time-eligible visits, which is revenue already earned and simply not captured.
E/M is the highest-volume code family in most practices. Small per-visit improvements in path selection compound into significant, fully defensible revenue — no aggressive coding required, just a deliberate choice where the rules already give you one.
Consult the current CPT E/M guidelines and payer policies; examples here are illustrative, not a leveling reference.
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Originally Published On: Medical Coding News
Photo courtesy of: Getty Images
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