Part B Coding Coach: Avoid Losing $35 Per Visit By Correctly Choosing Between 99213 and 99214

Why This Topic Matters

Accurate office visit leveling affects claim accuracy, compliance, and reimbursement. The article helps readers understand the broad documentation categories that influence whether a visit supports a lower or higher established-patient office visit level.

Article Sections

1. Rely on the Descriptor and Examine the Note

   Introduces the comparison between two established-patient office visit levels and emphasizes reviewing the encounter note. It frames the discussion around the core documentation components used for outpatient E/M leveling.

2. Recognize What Tips the History Scale

   Discusses the history component and the general factors that can move documentation toward a more detailed history level. It also notes concerns about artificially elevated documentation in electronic health records.

3. Count Systems and Determine the Detail of the Exam

   Reviews how exam detail is assessed and how payer guideline variation can affect interpretation. It describes general approaches used by payers when determining whether an exam is expanded or more detailed.

4. Use Three Factors to Get MDM

   Summarizes the major elements considered in medical decision making and the relationship between documentation support and the selected office visit level. It also highlights the role of medical necessity.

5. Don’t Look to Coding Based on Time

   Explains when time may be considered in selecting the service level and what general documentation elements should be present if time is used. It cautions against relying on time as the routine basis for level selection.