Is this visit a 99214 or a 99213?
Three small questions about Problems, Data, and Risk. Returns the office E/M code, the reason, and the documentation language that holds up to a payer downcode audit. Built to the 2021+ CMS rules.
What office E/M level is this visit?
2021+ CMS rules. Answers three small questions about the visit. Returns the code, the reason, and audit-safe documentation language.
1. Problems
Number and complexity addressed today
2. Data
Amount and complexity reviewed/analyzed
3. Risk
Risk of complications/morbidity/mortality of management
How the selection works
The 2021 office E/M revision changed how the code is chosen. Selection runs on the lower of any 2 of 3 MDM elements, or on total time on the date of service. The three elements are weighted equally.
1. Problems addressed
The number and complexity of problems addressed at the encounter. A stable chronic illness is Low. A chronic illness with exacerbation is Moderate. A life-threatening condition is High.
2. Data reviewed
Amount and complexity of data the clinician personally reviewed, analyzed, or ordered. Categories include external records, test orders, independent interpretation of tests, and discussion of management with an outside source.
3. Risk of management
Risk of complications, morbidity, or mortality of patient management. Prescription drug management is the most common Moderate-risk anchor. Decision regarding hospitalization or emergency major surgery is High.
Time path (alternative)
If MDM lands at one level but total time on the date of service supports a higher level, the visit can be coded on time instead. Time includes record review, examination, test ordering, charting, and care coordination. Patient-facing time alone does not count. Pick MDM or Time as the path, never both on the same visit.
Why this calculator exists
Office E/M is the most-audited line in physician billing. UnitedHealthcare, Anthem, Aetna, and several BCBS plans run automated downcoding algorithms that flag 99214 and 99204 claims for review and silently drop them to 99213 or 99203 when the documentation does not clearly support the selected level. Practices lose 8 to 14% of their E/M revenue this way every year and most never know.
The fix is not to undercode. The fix is to pick the level the visit actually supports and document it in language the audit reviewer cannot push back on. That is what this tool produces: the code, and the chart language that justifies it.
Frequently asked questions
How is the office E/M MDM level selected in 2026?
Office E/M codes (99202-99205 new, 99212-99215 established) are selected on the lower of any 2 of 3 medical decision making elements: Problems addressed, Data reviewed/analyzed, and Risk of complications. Alternatively the visit can be coded on total time on the date of service. This rule has been in effect since the 2021 CPT revision and continues to apply through 2026.
What is the difference between 99213 and 99214?
99213 is the established-patient office visit at LOW MDM (1 stable chronic illness, OR 1 acute uncomplicated injury, OR 2+ self-limited problems) or 20-29 minutes of total time. 99214 is the established-patient office visit at MODERATE MDM (1+ chronic illness with exacerbation, 2+ stable chronic, undiagnosed new problem with uncertain prognosis, acute illness with systemic symptoms, OR acute complicated injury) or 30-39 minutes of total time. The most common downcode pattern: payers downcoding a 99214 to 99213 when prescription drug management is documented but not the chronic illness exacerbation that justified the visit.
What counts as total time for an office visit in 2026?
Total time on the date of service includes review of prior records, examination, ordering or reviewing tests, counseling the patient, documenting in the EHR, and coordinating care with other professionals. It does NOT include time spent by ancillary staff. Patient-facing time alone is not the full time. The 2026 time windows are 99213: 20-29 min, 99214: 30-39 min, 99215: 40-54 min for established patients; 99203: 30-44 min, 99204: 45-59 min, 99205: 60-74 min for new patients.
Can I use both MDM and time on the same visit?
No. CMS rules require selecting the visit code on either MDM OR total time, not a combination of both. Pick whichever path supports the higher level for the documented work and apply that path consistently. Documenting both creates ambiguity that downcoding algorithms flag.
Why is prescription drug management considered Moderate risk?
Per the 2021 CMS office E/M guidelines, prescription drug management qualifies a visit as Moderate Risk because the prescription itself entails monitoring obligations and potential adverse effects. New prescription, dose adjustment, discontinuation, and refill of long-term medication all qualify. The chart must reflect the management decision, not merely the existence of an active prescription.
Office E/M code references
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Losing E/M revenue to silent downcoding?
We audit your last 90 days of 99213 and 99214 claims against payer downcode patterns. Free, no obligation. Most practices recover 8 to 14% of E/M revenue once documentation and tier selection are tightened.