This visit only meets one out of three criteria, so it can't be coded as a level 4 based on MDM. Going forward, the username you use to log into the system will always be the same as your primary email address on file. The problems are typically considered to be of low to moderate severity. Am I going to be able to do some basic therapy and bill this as a 99213 + add on code or bill it as a 99214 based on time? E/M Coding and Documentation Education. I don't see a reason to use an E&M code for a visit that included no E&M. Discussed depression. Remember the time for psychotherapy does not include time rendering the E/M service. Please click here to continue without javascript.. E&M Codes for Fun and Profit: A Story of 4 Psychiatrists, Starting Your Own Private Practice: A Business Model, Antidepressant Use in Pregnancy and the Risk of Autism, Medication Fact Book for Psychiatric Practice, Sixth Edition (2022), Using SAMe In Clinical Practice with Garrett Rossi, MD, Interpreting Assessment Discrepancies from Multiple Sources, Patients with 1 problem: Document the problem, one medical review of system (ROS) item, which can be psychiatric (eg, denies anxiety), and at least 6 items from the mental status exam. endstream endobj 641 0 obj <>stream Cardiovascular - Negative for chest pain, orthopnea or PND No: No tests were ordered. Im 98% 99214, 2% 99215. We are your billing staff here to help. Example Psychiatric Note 99214 PDF Download. It is a HCPCS Level II code (CPT codes are HCPCS Level I), part of the HCPCS system used by Medicare and Medicaid. It can most commonly be achieved when a consultation with a specialist (e.g. Requires all THREE Key Components (Hx,Exam,and Decision Making) Jump to first page 26 Established Patients -Think : 99212 -One stable condition 99213 -Two stable problems, OTC tx. 668 0 obj <>stream 6+ Psychiatric Progress Note Examples in PDF | Examples Messages. Assessment, For a detailed breakdown of this note with tips and advicesee99214 E/M Insight, An established office patient with hypertension, diabetes and a history of dyslipidemia, Repeat renal profile, spot microalbumin/creatinine at next visit, along with cbc, Check LFTs at next visit as well due to ongoing statin therapy, Continue lifestyle modifications and exercise for weight loss. This can save valuable time in patient intake and with screening the patients and monitoring their progression, even in between appointments. Psychotherapy Medical Billing & Coding Guide for 2023 - Neolytix CPT 99214 | How To Bill Level 4 Office And Outpatient Visits (2023) Rule changes that eliminated the history and exam portions from coding requirements should make it easier to identify level 4 office visits and code them for appropriate reimbursement. CPT 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. In more severe cases, perhaps even a referral may be set in motion for a mental health professional. zx} bf Psychiatry codes 99212 through 99215 and 99202 through 99205 are differentiated by clients being new or established. I cannot capture in words the value to me of TheraThink. Psychiatrists are often called upon to prepare reports about the patient for many participants in the healthcare system. I don't think that the reviewing 3 external notes is a requirement to hit 99215 in CoD if you're meeting 2 of the other criteria (NEEDING collateral, ordering unique tests, interpreting unique tests). This is a good way to start a note because the reader knows right at . One x-ray or electrocardiogram (ECG) interpreted by you. That means that for an outpatient E/M office visit to be coded as a level 4 (for new or established patients), you need at least two of the three elements to reach the moderate category moderate number and complexity of problems addressed; moderate amount and/or complexity of data to be reviewed and analyzed; or moderate risk of complications and/or morbidity or mortality of patient management. But all practices are different, and some coding variation is normal. Code it as a level 4 using total time. What Is a 99214 Code | Thriveworks These services are often not reimbursed by insurance companies. Coding Level 4 Office Visits Using the New E/M Guidelines | AAFP They are used for office visits with established patients being treated for medical and mental health conditions. HVKo6+s5MR%S4&q*Z!u:[Y;D>y7Y~jo Anxiety is also well controlled. This is actually the simplest part of billing with CPT Code 99214. He denies chest pain, fast heart rate, headache, flushing, or nose-bleeds. Its important to keep this in mind when working on your mental health insurance credentialing applications. Based on current E&M guidelines I consistently meet criteria & bill for 99214/90833. Therefore, it is no surprise that CPT Code 99214 is used the most frequently for this form of visit. endstream endobj 209 0 obj <>stream Here are three questions you can ask yourself to quickly determine whether you've just performed a level 4 visit: Was your total time between 30 and 39 minutes for an established patient, or between 45 and 59 minutes for a new patient? Environmental Intervention for Medical Management Purposes on a Psychiatric Patients Behalf With Agencies, Employers, or Institutions. It might also be used for procedures that require some degree of explanation or justification. I am concerned the 2021 CPT code changes are going to have a negative impact on my billing. HEENT: No JVD or carotid bruits Learn how to offload your mental health insurance billing to professionals, so you can do what you do best. Denny has interviewed hundreds of mental health practitioners to better understand their struggles and solutions, all with the goal of making the professional side of behavioral health a little easier, faster, and less expensive. I guess it really just depends on whether or not you have a patient that wants to discuss medications the entire length of a 20 minute visit or are they willing to discuss their life stressors. e !1AQ"Taq2BS34CDR Personal belief: If you spent the time, effort and money to go through psychiatry residency +/- fellowship, you should be able to decide if you're doing "16+ minutes of psychotherapy" - not the insurance company. CPT. hb```"fUaf`e`s4 This code is used for services not specifically defined under another code. Autism spectrum disorder, ADHD, other specified anxiety disorder. The rest involve supportive psychotherapy. PERRLA. However the pts need to be seen frequently and thus the MDM is sufficient to justify 99214 for my pts. Domiciliary/assisted living/ rest home codes . Explanation: Total time for this visit was 20 minutes (but not documented in note). Psychiatry CPT Codes are numerous and nuanced. HnHj/` vv. xWzWnwaGjQ6(rQ'CpHD!BMJz|F ,0nm315&2(erbR~bc{,C8g+P`~p9U 8%;DTw!J JaJH)Re;z(DJ'\P{YUfVq^j is=pY"2,zx2`|oIqJ 8zO3?G Discussed fever and pain control. They are part of HCPS, the Healthcare Common Procedure Coding System. For more information on other ways to bill and increase your practices revenue, check out our articles on CPT Code 96127 and CPT Code 96103: CPT Code 96127 Answers to the frequently asked questions about billing this code, 3 Online Screenings That Can Be Billed with CPT Code 96127, CPT Code 96127 How to Increase Revenue with This New Behavioral or Emotional Assessment, CPT Code 96103: How to Increase Revenue and Bill with Psychological Testing, http://thehappyhospitalist.blogspot.com/2013/09/99214-CPT-Procedure-Code-Description-Examples-RVU-Distribution.html, https://www.cgsmedicare.com/partb/mr/pdf/99214.pdf, http://bh.medicaid.ohio.gov/Portals/0/Users/008/08/8/Coding-Documentation-for-Behavioral-Health-2016-Zucker.pdf?ver=2016-06-01-182611-063, http://www.mdedge.com/jfponline/article/63368/practice-management/10-billing-coding-tips-boost-your-reimbursement, https://www.cgsmedicare.com/partb/mr/pdf/99213.pdf, http://www.hcca-info.org/Portals/0/PDFs/Resources/Conference_Handouts/Clinical_Practice_Compliance_Conference/2010/Sun/P3_BrembyFriedelPPT-PDF.pdf, https://emuniversity.com/Level3EstablishedOfficePatient.html, http://www.medicarepaymentandreimbursement.com/p/medicare-fee-schedule-for-office-visit.html. is the driving factor to determine if low-level or moderate-level care is given. We established a mental health billing service at TheraThink to help you stay away from all this jargon so you can focus on what you do best. Breathing is nonlabored. 30 minutes, Psychotherapy provided alongside evaluation and management services. It offers higher revenue/reimbursement than some similar CPT codes, including CPT Code 99213. The E/M code goes first with no modifier, then the appropriate add-on psychotherapy code 90833, 90836, or 90838. whenever the therapy is done by the same provider who performed the E/M service. I try to be extremely literal about this question. Start: Dec 1, 2022 Get Offer. *kT1Rq:/(Rr9[>YsvYNz"gRRIk2:Os]o.YS!k|:tj_;p]qM5*BjF-]&Mj{Kc8emt/6MrL5R.85'VYM+/g-nV-%cWu:S6{Q:[{_Ws'4.3I{Ti_|]W4.sYy{{y#Nh]W3'4.k&y$E: : 4iy8Xm}#m&{o\>+3\]Gcjrh{hW$xs=v1n.n5ee)4X6vI$}[Vh5gBkkCRk(^{]n5Fv;s8}IJqiU%%u}Ei0;ryu8g]~5 sRuit|)| uJ{(w3:+K.D(oP li9M-~~iiKT2392J_cEC&j_mp>M>[D4FOnVQ2r=Sbk+K0y.Rq)6j7!975ii6'4Im-kYU,*&W-y(R0tV0xS10Z"63-.4Dl&|$H`h(K"884d%;DMsj{rp{%(9Rt"Jx+vfQ[EY2%pht38VUF%u0Yva>Z2GLNYkc9&gzws6E,Yvi-jWfZF[ E5M'HY^>C&E"JU! You want to get paid quickly, in full, and not have to do more than spend 10 or 15 minutes to input your weekly calendar. Outpatient Mental Health CPT Codes: 90832 - Psychotherapy, 30 minutes ( 16-37 minutes ). Some insurance companies only pay 15% over the Medicaid rate in their state, whereas others pay 45%, 60%, 80%, 85% on top of their states medicaid rate. This has especially been the case since changes were made back in 2013, along with the Affordable Care Acts inclusion of mental healthcare in 2006. General: NAD, conversant It can be used to bill for an in-office visit or in an outpatient setting. Has a 3 day hx of sore throat, fever, and fatigue. Answering three basic questions can help you identify whether you've performed a level 4 visit. This service is covered by some insurance plans, but because some of the activities are not face-to-face, the clinician should check with carriers about their willingness to reimburse for this code. 90834 - Psychotherapy, 45 minutes ( 38-52 minutes ). Did you order/review level 4 data and manage level 4 risk? PDF Outpatient/Office Psychiatric Progress Note Counseling And/Or E/M Services Guide: Coding by Key Components (summary chart). 99213 vs 99214 question - more in comments : Psychiatry - reddit Cpt Codes 99213 And 99214: Behavioral Assessment Billing. Two problems that are stable: also 99213. My daily insurance billing time now is less than five minutes for a full day of appointments. Physicians typically spend 25 minutes face-to-face with the patient and/or family. September/October 2020 Countdown to the E/M Coding Changes, November/December 2020 The 2021 Office Visit Coding Changes: Putting the Pieces Together, January/February 2021 Coding Level 4 Office Visits Using the New E/M Guidelines. I'd be very interested to know where 90837s pay cash about equal to 2x 99214 (unless the later is billing something like Medicaid prices and is already comically low). CPT 99211, 99212, 99213, 99214, 99215 - Established patient office This definitive guide will help you avoid under-coding and allow for more accurate billing. a psychologist or a psychiatrist) is required. CPT DOCUMENTATION REQUIREMENTS FOR E/M CODE 99214 WITH AN ADD-ON PSYCHOTHERAPY SERVICE When an E/M office visit is provided together with an add-on psychotherapy code (90833, 90836 or 90838), the E/M code must be documented based on elements, not time. Level 4 office-visit coding - Contemporary Pediatrics Copyright 2023 American Academy of Family Physicians. 90846 - Family or couples psychotherapy, without patient present. CPT Coding Guide for Psychiatry | SonderMind Physical Exam A: In all likelihood the insurer is correct in suggesting that 99214 is too high a level for a patient who is stable, even though the patient has complex physical and psychiatric symptoms that are being kept in abeyance by the ongoing care you (and his other physicians) are providing. They are all part of HCPS, the Healthcare Common Procedure Coding System. Correct but then you kinda have to make that decision partway through the encounter. For example, they can be used in primary care or OB/GYN offices. How to Code for Complex Yet Stable Patients | Psychiatric News You'll always be able to get in touch. Handout given. Consultation codes 99242-99245, 99252-99255 have clarifications, and 99241, 99251 deleted. "*e+aUw=CMIR0GK!ySS$o0mb/yRT1\FU.Mr"/&DE4Wlgp)pLa${yWS#aUG:Ub:TU!tL{yUFdt^TcI}%p6B \ l1N(cLS/35{{s!-BAyiKePio35rJ4@[iF3]c 2023 Carlat Publishing, LLC and Affiliates, All Rights Reserved. In such cases, rehabilitative, evaluation and management (E/M) codes should be reported. / But the definitions have changed somewhat (see CPT E/M office revisions: level of medical decision making). This modifier is used when the work associated with the service provided is greater than that usually required for the listed code. This post will give you insight into billing for procedure code 99214. Assessment/Plan: Essential hypertension I10. Reach out for help from us about suggestions! Many medical professionals can bill with CPT Codes 99213 and 96214. Decision about major elective surgery without identified risk factors for patient or procedure. 256. Evaluation and Management (E/M) Patient Examples 99214 Office visit for a 13-year-old male, established patient, with depression, anxiety, and anger outbursts. Reaction score. Please review the Medicare guidelines for E/M guidelines and documentation for exhaustive detail: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. Consider hiring a team of billing experts at Therathink. The national average for family physicians' usage of the level 4 code (99214) is slowly increasing and is approaching 50% of established patient office visits (it's now above 50% for our Medicare patients).2. Atorvastatin 10 mg po qd Billing a 99214 with a typical time of 25 minutes but repeatedly subtracting only 10 minutes to attribute more time to the psychotherapy portionbecause you believe you can do the E/M work much faster than your colleaguesmay raise questions in an audit. Make sure to review our list of the most common insurance billing procedure codes for psych services: Here is a downloadable Psychiatry CPT Code Cheat Sheet PDF: If you need help choose the right CPT code to use for your insurance claims, we help translate billing into English with our mental health billing service. hbbd``b` $k@t 2Hp w n"$@``&@BH,.f`bd)'` I have better things to do, like take care of my patients.. From what I can gather, many of my visits will meet criteria for 99213/90833 . While the detailed or expanded exams are fairly commonplace, as well as easily achieved, most of the questions come in regarding the history and decision-making components. You'll always be able to get in touch. If youre not changing anything Im willing to bet the vast majority of our patients have 3 or more problems. Tripped over dog and turned ankle in. Medical decision making is still made up of three elements: problems, data, and risk. In my opinion, it's a lot simpler to document in order to meet the history and exam criteria than the MDM complexity. In order to bill 99214, you need 2/3 of either a detailed history, detailed exam, or moderate complexity MDM. Denny has interviewed hundreds of mental health practitioners to better understand their struggles and solutions, all with the goal of making the professional side of behavioral health a little easier, faster, and less expensive. Jq52=-B%mC?]s-W.Yt$firn(1 Medicare reimburses for procedure code 99214 at $141.78. PDF Example Psychiatric Note 99214 / freewebmasterhelp Hospital inpatient services codes revised to include observation care, and codes 99217 - 99220, 99224- 99226 deleted. Two stable chronic illnesses (e.g., controlled hypertension, diabetes, chronic kidney disease, or heart disease). , whether the visit is conducted in the office or in an outpatient atmosphere. A great example of a primary care doctor using CPT Code 99214 is when an existing patient comes in for a routine health examination for chronic pain. The 3 Month (100 Day) MCAT Study Schedule Guide: 2022 Edition, https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf, All resources are student and donor supported. However, the flow of conversation may quickly turn to feelings of depression that are now accompanying this pain. With 99214 , it is possible when there has been a new diagnosis (e.g. Our mental health insurance billing staff is on call Monday Friday, 8am-6pm to ensure your claims are submitted and checked up on with immediacy. Thyroid is not enlarged. Eligibility & Benefits Verification (in 2 business days), EAP / Medicare / Medicaid / TriCare Billing, Month-by-Month Contract: No risk trial period. Discussion of the patient's management or test results with an external physician (one from a different medical group or different specialty/subspecialty). PDF 2021 E&M Coding Tool - PCC Learn 99213 versus 99214: Are You Coding Correctly or - Pat Bass In general, doctors with more elderly patients usually have a higher percentage of level 4 visits. We are your billing staff here to help. Coding should be easier with the removal of the history and exam components, allowing us to focus more on treating our patients. General Surgery Sample Doctor 6,861 1,990 4,871 7,259 2,388 4,871 % Increase in Outpatient E/M wRVUs under 2021 Rule Internal Medicine 28% Allergy/Immunology 22% General Surgery 20% AMGA Production To make this simpler, let's substitute level 4 for the term moderate as we take a look at what qualifies in each category (problems, data, and risk). NECK: Benign. However, this code is extremely popular, being the second most used among middle level billing codes. One acute complicated injury (e.g., concussion). Sprain left ankle, initial encounter S93.492A, is mild and improving. However, it can also be even more easily collected through assessments that are filled out in the waiting room. But then you cant bill a therapy add on code, I have always been told the MDM is implied as the driving factor. Reimbursement like RVU generation or reimbursement like payment from insurance company? Any time under 16 minutes of psychotherapy should not be billed as a psychotherapy add on. Another way to accomplish it without note bloat is to have a pop-up message with this information that appears in the EHR whenever patients access their notes. Watches his wt and exercises. By using the three questions presented in this article, as well as the patient examples, you should be able to more confidently code level 4 visits and make sure you're getting paid for the amount of work you're doing. N*P[V&}zpsRnE[gQQ)!:^923LN6:[;^2/%SSzjCFOi This chart helps better visualize the CPT codes by time. RTC for BP check in 3 wks, sooner if problems arise. PHQ-9) may also be used to gather more detailed information. At that point you are an -entire- patient behind. Objective: T 100.2, P 96, R 18, BP 110/70. 2uZL XY!LcL6g!xR \P)P`=|67YFNO` t L Bilateral ankle exam: L ant drawer is negative, inversion testing on L causes pain, focal mild tenderness and swelling just below L lat malleolus. Let us handle handle your insurance billing so you can focus on your practice. However, this code is extremely popular, being the second most used among middle level billing codes. While I personally would raise my eyebrows about this, if you genuinely believe you are providing 16+ mins of psychotherapy in the visit that is separately identifiable from the E&M component, and document the modality, techniques, goals, frequency, and measurement of progress, and are not conflating counseling and motivational interviewing with "psychotherapy" then technically this is defensible. TheraThink provides an affordable and incredibly easy solution. While these two codes are within the same family, they do have different regulations for reimbursement. Once you know the ins and outs of both codes, choosing which one to bill is actually quite simple. #$%&'()*56789:EFGHIJUVWXYZbcdefghijrstuvwxyz !AQ1B2Raq The primary changes in the CPT codes include: developmental test administration neurobehavioral status exam psychological testing and evaluation neuropsychological testing and evaluation. Free Account Setup - we input your data at signup. Why does frequency of visit mean these questions don't need to be asked? Revised Prolonged Services code 99417, new 99418, deleted codes 99354-99355, 99356- 99357. You want to get paid quickly, in full, and not have to do more than spend 10 or 15 minutes to input your weekly calendar. Every provider we work with is assigned an admin as a point of contact. Additionally these are the only two outside insurances the dept lets us take so I assume the rates offered by the others were not acceptable. Patients with 3 problems: Document the problems, the social history, 2 ROS categories, and the prescription of a medication. Our data is encrypted and backed up to HIPAA compliant standards. Both of these CPT (Current Procedural Terminology) Codes are part of a particular family of billing codes, including 99211-99215. You must log in or register to reply here. Since 2013, all psychiatrists have had to use new CPT (Current Procedural Terminology) codes. Performing level 4 evaluation and management (E/M) outpatient visits but coding them as level 3 visits is a costly mistake for family physicians. 205 0 obj <> endobj X#aUraLAUGUqb(:^ hj0o@B6kl#Cb[Hn&[3`0Y9G7s You may want to include a short definition of total time so that patients who read their notes don't confuse it with face-to-face time and think, My doctor only spent 20 minutes with me, not the 40 minutes listed here. For example, your documentation could say, Total time: 40 minutes. The good news is that it is not only for mental health providers or therapists. Free Account Setup - we input your data at signup. Also, what do you do with people who are, say, six minutes late to their appointment? Hypnotherapy may be used for either diagnostic or treatment purposes. (2;4222;;;;;;;;;;;;;;;;;@@@@@;@@@@@@@@@@@@@@@@@@@@@ $2(! This guide will also help you find out which codes to pick. Although this would seem to be a very useful code, because reviewing data is not a face-to-face service with the patient, Medicare will not reimburse for this code and some commercial carriers have followed suit. The notes/collateral/tests thing is definitely an 'or', but you have to do at least three total things from those categories. Note: We only work with licensed mental health providers. Two out of three criteria meet the requirements for a level 4, so code it as a level 4. It may not display this or other websites correctly. RTC 72 hours, RTC or ER sooner if red flags occur. Standardized assessment tools for depression (e.g. Yes: Prescription drug management. Was level 4 data ordered/reviewed? No: two lab tests. Cipro 500 mg po bid x 7 days with appropriate precautions. EXAMPLES ONLY: Prescription drug management Decision regarding minor surgery with identified patient or procedure risk . CPT Coding - New York State Psychiatric Association Nov 15, 2006. However, the flow of conversation may quickly turn to feelings of depression that are now accompanying this pain. endstream endobj startxref Total time includes all time the physician or other qualified health professional (QHP) spends on that patient on the day of the encounter. 99204 45-59 minutes 99214 30-39 minutes 99205 60-74 minutes 99215 40-54 minutes A new prolonged service code (99417) was created for use when . Healthcare providers will be able to provide a higher level of care for their patients by discovering mental health issues. CPT Code 99214 can be used as part of the second highest level in care for a patients visit. How to use CPT CODE 99214 Correctly? examples of E/M codes across specialties An attempt was made to revise the office and other outpatient examples Not enough specialties participated CPT decided to hold off on example revisions for the new code definitions For now, examples related to these code have been deleted Nonetheless, AACAP and APA collaborated on No cervical adenopathy. Hitting 99215 in CoD isn't necessary though if you're hitting it in the complexity of problems and patient management categories, which is far more common/easier to meet imo. These descriptions are directly copied from the American Psychiatric Associations coding pamphlet. You can call, text, or email us about any claim, anytime, and hear back that day. Standardized assessment tools for depressio. Office visit for a 70-year-old male, established patient, with stable depression and recent mild forgetfulness. You free me to focus on the work I love!. r mq:}=c0uijWjFOj["aw|te4voMxXuNte;OhV ][:eW-^2{];N>$hfRcTeklIf9)V*uWrjmCL:xFPjw\e This is not a comprehensive list of CPT codes. They can be used to increase the complexity of visits and thereby qualify for billing with a higher code (e.g. CPT code 99214: Established patient office or other outpatient visit, 30-39 minutes As the authority on the CPT code set, the AMA is providing the top-searched codes to help remove obstacles and burdens that interfere with patient care. Extremities: No peripheral edema ]^'&0*3+m/TCS -+rRekULUN{"WeV-%iYIUb%ZG11y\-4{yp"S.HcHC354&yyP1o0BKr:VlW&o0BUnEJc(AH^`VeCo0*X^aVGATC`WR# %/0.1PU0.T"3\cDqLo3546.o35iKu /0BU#-F+*]BICO!U1aVL^- u,/0L$CS1"1$&[# A great example of a primary care doctor using CPT Code 99214 is when an existing patient comes in for a routine health examination for chronic pain. Neurologic - Negative for paresthesias n (e.g. The program covers both the 2021 guidelines (for office-based psychiatry services) as well as the 1997 guidelines, which are still used for hospital-based psychiatry . Psychological and Neuropsychological Testing Codes (CPT codes 96105-96146) Listed below are the most common psychotherapy CPT codes, as well as which healthcare professionals can report which codes. Medicare will not reimburse for this service because it is not done face-to-face with the patient, and clinicians should verify coverage by other insurers to ensure reimbursement. CPT Code 99213 is a level three code that should be used for an established patient. RY CC 13-year-old male seen for follow up visit for mood and behavior . Current Guidelines -99213/99214 2021 Guidelines -99212 based on time, 99213/99214 on MDM Medical Decision-Making Low/Moderate: Acute, uncomplicated illness or injury -99213 OR Acute illness with systemic symptoms -99214 Straightforward: No data reviewed -99212 Moderate: Prescription drug management -99214 21 Example - At that point you are an -entire- patient behind. A level 99214 visit history also requires 1 of 3 elements for PFSH that is pertinent to the presenting problem. Paneled with a bunch of commercial insurances. However, here's the breakdown for coding the visit based on MDM: Was there a level 4 problem? These terms or unique code tends to be uniform all around The United States, which helps in effective billing. The level of MDM should be driven by the nature of the presenting problem on the date of the encounter. 2021 E&M Changes - Putting it All Together - DoctorsManagement