EM Coding Alert

See whether you can identify elements of MDM to level these encounter scenarios.

Often, coders have trouble identifying the level of medical decision making (MDM) in a given evaluation and management (E/M) encounter.

CJ Wolf, MD, MEd, COC, CPC, CPB, Clinical Assistant Professor at University of Illinois at Chicago College of Medicine, shared case studies to highlight how coders can evaluate encounter notes for elements of MDM in his presentation “E/M Case Studies in Medical Decision Making” at AAPC HEALTHCON 2026.

Look for the emphasized phrases in these two scenarios to pick out aspects of encounter documentation that support E/M leveling according to Wolf’s expertise.

Scenario 1: New Patient at Rheumatology

31-year-old Caucasian female presents as a new patient at rheumatology office upon the recommendation of her primary care physician (PCP) from another practice.

She complains of 2 years of intermittent, unexplained fatigue, joint stiffness, and fevers. In the last three months she has had unexplained rashes, especially after sun exposure.

The patient denies memory loss or confusion but her husband, who accompanies her today, independently reports she has definite episodes of confusion and memory loss shortly after these other symptoms appear.

The patient and husband’s history is consistent with my review of the medical record her PCP sent me. This also included my personal interpretation of her most recent electrocardiogram (ECG) tracing a month ago, which is normal and noncontributory.

Today she doesn’t complain of any symptoms and her physical exam is unremarkable. Differential diagnosis includes systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Sjogren’s, and fibromyalgia. I am ordering typical SLE labs including an anti-nuclear antibodies (ANA) (if positive, then ANA panel/ENA panel), antiphospholipid labs, complement components, comprehensive metabolic panel (CMP), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and urinalysis (UA). Recommend she returns to clinic quickly when symptoms flare per SLE protocol; no other treatment warranted at this time.

When looking at this scenario to evaluate for E/M level, you’re looking to see whether there are certain elements present: number and complexity of problems, data analyzed, and risk management. This scenario involves:

• Independent historian, which may “count” for this scenario because of the possibility of confusion and memory loss
• Review of external records
• Undiagnosed new problem
• Data — A “unique” test is defined by whether it has a CPT^® code

Wolf broke down the elements in a table, showing how they together support moderate MDM:

“The patient can have big problems, and we can see that the data analyzed was high, and the number and complexity was moderate, so we get a lot of work done there. We just don’t happen to get a lot of it on the risk of management because it’s watchful waiting,” Wolf explained.

Wolf said you could probably code this encounter with 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.).

Scenario 2: Arrhythmia Follow-up

72-year-old male status post (s/p) myocardial infarction (MI) while out of state presents for follow-up after I prescribed 800 mg amiodarone loading dose 3 weeks ago when arrythmia developed. He’s here for follow-up before standard reduction to 400 mg over next 4 weeks until we reach our goal of weaning him.

Patient suffers from moderate dementia and is an unreliable historian. His wife is the primary caretaker and reports compliance with medication and no episodes of syncope, chest pain, other cardiovascular symptoms, or other signs of amiodarone toxicity. She reports he has energy and good appetite.

After reviewing cardiac monitor interrogation data and personally reviewing ECG from out-of-state MI compared to current ECG performed in office today, we’ll proceed with the amiodarone dose reduction. We will perform ECGs every week for next six weeks, as well as order liver function tests (LFTs), electrolyte panel, and serum magnesium (Mg) given potential toxicity from amiodarone.

Some decisions made by providers may be clinically important without contributing to the E/M level, like when a physical exam and history are essential in determining toxicity. If you’re talking to a provider, you can compliment their care (or offer no judgement) and say that only some aspects of an encounter count toward E/M.

In this scenario, the provider evaluated a problem, analyzed data, and actively monitored the patient for drug toxicity (a category of risk of management), all of which contribute to MDM. The provider personally reviewed ECG, amiodarone dose, reduction, monitoring, and lab tests.

According to CPT^®: “A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. Monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy.” So, in this scenario, the provider is monitoring for toxicity rather than efficacy.

“The monitoring should be that which is generally accepted practice for the agent, but it could be patient-specific in some cases. A medication, 80 percent of the time, might not need monitoring for toxicity, but if a patient has kidney failure or liver failure or some other issue that’s unique to that patient, that drug might need to be monitored for toxicities,” Wolf said.

In this scenario, there’s definite documentation that there’s monitoring via lab tests and ECG, Wolf noted. To determine whether the prior visit, with the initial prescription of amiodarone 800 mg, counted toward toxicity monitoring, you’d have to look at the note. However, simply prescribing the amiodarone doesn’t count — that’s considered prescription drug management.

“It’s really important that the clinician documents the drug, why you’re monitoring it for toxicity, what are its effects, and how are you monitoring it,” he said.

Additionally, although the wife said there’s no evidence of amiodarone toxicity, which is important clinically, unless the provider documents a test that they ordered to monitor, it wouldn’t count toward MDM, he explained.

Here’s a table to show Wolf’s evaluation of possible MDM elements in this scenario:

Wolf said that this encounter would probably be coded as high MDM, with E/M code 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) and 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) for the ECG.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC