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

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.

See the revenue you're owed but never collected.

A free assessment shows your real recoverable number from denied and underpaid claims. No risk, paid only on what we recover.