Am I coding my E/M visits correctly under the 2021 rules?
Since 2021, office-visit E/M levels are chosen by either total time on the date of service or medical decision-making (MDM), not the old history-and-exam bullet counting. Most under-coding comes from not documenting time or the true complexity of decision-making; most over-coding from billing a level the note doesn't support.
What actually matters
- Pick the level by total time OR MDM, whichever is higher and documented
- When you bill on time, state the total time explicitly in the note
- Capture the real MDM complexity — number of problems, data reviewed, and risk
- Use modifier 25 for a separate, significant E/M on a procedure day, documented on its own
- Under-coding is as costly as over-coding and far more common — many practices leave a level on the table on every visit
Common questions
What supports a 99214 versus a 99213?
A 99214 needs moderate-complexity MDM or the higher total-time threshold, documented. The note has to show the complexity or the time — the code follows the documentation, not the other way around.
Where Volari fits: When a payer downcodes a supported E/M, Volari catches it by reconciling the billed code against the paid code — the denial that never shows as a rejection.
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