Dilemma—you recently converted to an electronic medical record (EMR) system with an automated coding function, and now the majority of your visits for conditions that are typically a low-level risk with low complexity medical decision-making (eg, upper respiratory infection, pharyngitis) are being coded as level 4 visits for established patients (99214).

Evaluation and management (E/M) code level of service is based on the performance and documentation of the required key components (history, physical examination, and medical decision-making, or time if more than 50% of the face-to-face encounter is spent in counseling or coordination of care). Therefore, if documentation supports a detailed or comprehensive-level history and physical examination on every established patient, a higher level of E/M service technically could be reported because only 2 of the 3 key components are required for an established patient office visit (99212–99215). However, coding guidelines further stipulate that only the...

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