1. What is E/M Level?

Evaluation and Management (E/M) levels categorize the complexity of patient encounters in medical practice. These levels (1-5) determine appropriate billing and documentation requirements.

2. How is E/M Level Determined?

E/M levels can be determined by either:

• Medical Decision Making (MDM): Complexity of diagnosis/treatment
• Time: Total time spent on the encounter

Key Components:

• Number and complexity of problems addressed
• Amount/complexity of data reviewed
• Risk of complications/morbidity

3. Importance of Correct E/M Level

Details: Proper E/M level selection ensures accurate billing, compliance with regulations, and appropriate reimbursement for services provided.

4. Using the Calculator

Tips: Select the MDM complexity level and/or enter total time spent. The calculator will determine the appropriate E/M level based on 2023 guidelines.

5. Frequently Asked Questions (FAQ)

Q1: What changed in the 2023 E/M guidelines?
A: Office visit coding now uses MDM or time exclusively (not history/exam elements). Time thresholds were adjusted.

Q2: How is time defined?
A: Time includes all activities related to the encounter on the date of service (face-to-face and non-face-to-face).

Q3: What's the difference between level 3 and 4?
A: Level 3 requires moderate MDM, level 4 requires high MDM or significantly more time.

Q4: Can I use both MDM and time?
A: No, you must choose one method (MDM or time) to determine the level for each encounter.

Q5: Are there different rules for different specialties?
A: The basic rules apply to all specialties, but some specialties have additional documentation requirements.