Coding basics: Medical decision making is the key

October 1, 2018

Pediatricians need to document visits correctly to ensure continuity of care and to bill appropriately. Are you confident your office notes will pass muster with those inevitable insurance company audits?

The current coding system is more than 20 years old and was developed at a time when physicians did not use electronic health records (EHRs). As a consequence of EHR use, notes have become bloated, take too much time to complete, and are a significant contributor to physician burnout. I reviewed a variety of ways to expedite completion of office notes in the article “Expediting medical documentation” in the January 2016 issue of Contemporary Pediatrics. The purpose of this month’s article is to simplify the process of assigning codes for your most common visit types.

Whereas only a handful of studies look at how well physicians code for office visits, all conclude that physicians undercode their established patient office visits.1-4 The most recent study examined the notes from 351 senior resident family physicians in 2 programs in Tennessee.5 Expert coders found that 33% of visits were undercoded based on the documentation; 50% were undercoded based on the medical decision making; and 80% of the visits were undercoded based on the number of presenting problems.

Fortunately, the Centers for Medicare and Medicaid Services (CMS) is considering revising the coding guidelines. It is anticipated that CMS will relax requirements for the physical exam and history components of medical notes. This is expected to considerably reduce the documentation burden on providers.

A different approach

Providers have been “trained” to code by taking courses, reading articles, and having the office coders review your notes. We know that well-visit notes are straightforward and generally not susceptible to insurance scrutiny. The difficult part of coding is deciding whether an ill visit for an established patient should be coded as a 99213 (level 3) or a 99214 (level 4) visit. Physicians need to code correctly for services provided, neither downcoding for fear of an audit or upcoding to generate productivity or increase revenue.

I find that the best way to expedite coding is to decide during the visit whether it is a level-3 or a level-4 visit based on the medical decision making (MDM) involved and then document accordingly.

Your MDM depends upon just 3 factors:

·      The number of problems addressed/number of treatment options considered.

·      The data reviewed.

·      The risk involved.

This is a “bottom-up” or “backward” approach. By determining if you have a level-3 or level-4 visit, you can save considerable time by taking the history and performing the physical exam appropriate for the visit type.

Documenting a moderately complex visit

The elements of any note include: 1) the history; 2) the physical exam: and 3) the MDM.

To document the history sufficient for a 99214 visit (Table 1), your history should include the chief complaint (CC); the history of present illness (HPI); the past, family, and/or social history (PFSH); and the review of systems (ROS). The HPI should include at least 4 of the following descriptive elements of the presenting problem (let’s say ear pain): location (eg, left ear); duration (eg, 3 days); quality (eg, burning or stinging); timing (eg, intermittent or constant); severity (eg, 7/10 on pain scale); context (eg, associated with urinary tract infection [URI] symptoms) including any modifying factors (eg, improved with ibuprofen); or any associated signs or symptoms (eg, fever, vomiting). This can easily be accomplished with a few short sentences per problem. For example: “Patient presents with dull ache in left ear x 3 days. Patient reports pain is 7/10 in severity, constant, improves with ibuprofen, and is associated with vomiting and temperature to 102°F.”

A level 99214 visit history also requires 1 element for PFSH that is pertinent to the presenting problem. A statement of drug allergies, list of medications, or exposure to ill persons is usually sufficient to satisfy this requirement. Lastly, 2 or more pertinent elements of ROS should be documented to satisfy the history component of the 99214 visit. That’s it! These 99214 histories are easy to document and in the context of continuity of care, less is often more.

Documenting the physical exam component of the 99214 visit is similarly easily accomplished, and according to the 1997 guidelines requires examination of just 12 exam elements, including the patient’s vital signs. Table 1 also provides helpful guidance regarding elements required for coding new and established patients for level-3, level-4, and level-5 visits.

Medical decision making

The most complicated component of coding an office visit is to determine the MDM involved. The MDM is the element that rewards value for your cognitive abilities. The CMS recognize 4 types of MDMs: straightforward, low complexity, moderate complexity, and high complexity (Table 2).

The MDM quantifies the complexity of establishing a diagnosis and/or selecting a management option by measuring:

·      The nature of the presenting problem (the number of possible diagnoses and/or the number of management options that must be considered).

·      The data reviewed (the amount of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed).

·      The risk of significant complications, morbidity and/or mortality associated with the patient's presenting problem(s); the diagnostic procedure(s); and/or the possible management options.

The MDM requirement of documenting an office visit is confusing and even frustrating at first look. Remember that the 99214 visit requires moderate MDM, which in turn requires adequate “passing scores” relating to 2 of the 3 components above-risk, amount of data reviewed, and the nature of the presenting problem. To decide on a level of MDM, you need to keep a coding sheet like the one in Figure 1 handy. To bill for moderate MDM, your documentation must achieve at least 2 of the 3 following criteria on the coding sheet: 1) 3 problem points or higher, 2) 3 data points or higher, and 3) moderate risk in the risk table. As stated above, in my experience, the best approach to an established patient visit is to determine the level of risk at the time of the patient visit by assigning the highest applicable level of risk in the risk table.

You can see from the risk table that in pediatric practice, those patients who qualify as moderate risk most often present with:

·      One or more chronic illnesses with mild exacerbation, progression, or adverse effects of treatment (asthma exacerbation, attention-deficit/hyperactivity disorder [ADHD] not responding to medication).

·      Two or more stable chronic illnesses (asthma, enuresis).

·      Undiagnosed new problem with uncertain prognosis (eg, blood in the stool).

·      Acute illness with systemic symptoms (eg, pyelonephritis, pneumonitis, colitis).

·      Acute complicated injury (eg, head injury without loss of consciousness).

·      Conditions that require prescription drug management.

If a patient falls into the moderate-risk category, then the provider determines the number of problems addressed at the visit as well as the data reviewed and assigns a point value to this information using the coding sheet. Remember that 3 or more problem points or 3 or more data points are needed to qualify a visit as a 99214 level as long as the problem or problems fall into the moderate risk level. If you determine that the visit should be assigned moderate MDM, make sure you document the necessary elements for the history and/or the physical exam to qualify your visit as a 99214 visit. Figure 2 is an example of documentation for a 99214 visit.

Coding by time

If you spend more than half of the visit counseling the patient or parent or coordinating services, you can circumnavigate many of the coding requirements by adding a statement at the end of your note documenting the time spent and detailing what was discussed. For a 99213 visit, this time threshold component is 8 of 15 minutes, while for a 99214 visit it is 13 of 25 minutes.

Other coding nuances


Keep in mind that insurance companies prefer that every ill visit is level 3 and will flag and often challenge level-4 visits and scrutinize your documentation. You can reduce the possibility of an audit by listing all appropriate diagnosis codes associated with your visit, and, whenever possible, code by time if the visit warrants. If there is any area of your note that merits verbosity, it is in the assessment and plan. Indicate the problems addressed, workup planned, and recommendations made for each diagnosis made at the visit. By doing so, you will reduce the likelihood of claim denial and generate the appropriate compensation for your services.



1. King MS, Sharp L, Lipsky MS. Accuracy of CPT evaluation and management coding by family physicians. J Am Board Fam Pract. 2001;1(3)4:184-192.

2. Kikano GE, Goodwin MA, Stange KC. Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice. Arch Fam Med. 2000;9(1):68-71.

3. Chao J, Gillanders WG, Flocke SA, Goodwin MA, Kikano GE, Stange KC. Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation. J Fam Pract. 1998;47(1):28-32.

4. King MS, Lipsky MS, Sharp L. Expert agreement in Current Procedural Terminology evaluation and management coding. Arch Intern Med. 2002;162(3):316-320.

5. Holt J, Warsy A, Wright P. Medical decision making: guide to improved CPT coding. South Med J. 2010;103(4):316-322.


6. US Department of Health and Human Services; Centers for Medicare and Medicaid Services. Evaluation and Management Services. Baltimore, MD: Centers for Medicare and Medicaid Services; 2017. Available at: Accessed August 1, 2018.

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