Your CPC is the beginning—not the finish line.

10 E/M leveling reminders every coder should know

1. Choose the correct E/M category before selecting a level: setting, patient status, and service type matter.
2. For MDM-based leveling, two of the three MDM elements must meet or exceed the selected level.
3. Problems: evaluate number and complexity—not simply the number of diagnoses listed.
4. Data: count only qualifying tests, documents, historians, interpretations, and discussions under current CPT rules.
5. Risk: use the risk of patient management addressed at the encounter, including prescription-drug management when supported.
6. Do not use history and exam to determine the office/outpatient E/M level; they must still be medically appropriate.
7. New versus established patient status changes the available code range and must be determined correctly.
8. When coding by time, use the qualifying total time on the date of service and verify which activities may be counted.
9. Review separate-procedure, modifier 25, and global-period rules when E/M occurs with another service.
10. Never level an encounter from a template, diagnosis list, or medication list alone—follow the documented work and current-year guidance.