An Optometrist's Guide to Navigating Changes to Medical Exam Coding

Jun 2, 2020
9 min read

Starting in 2021, the Centers for Medicare & Medicaid Services (CMS) plans to remove some of the documentation requirements for medical exam (E/M) codes (99xxx). Let’s take a look at what is changing.

Current exam coding rules

As of now, Medicare and many other insurance providers require that doctors satisfy 3 areas of documentation in order to properly bill an E/M code. Those areas include:

  • Patient History
  • Examination Elements
  • Medical Decision Making

Under this system, a doctor has to ensure she asks the patient enough questions during the patient intake, examines a certain number of ocular areas, and determines how complex the case is to pick a proper exam code. While well intentioned, this system has resulted in the collection of a huge amount of unnecessary information. For example, a patient may have come in for acute viral conjunctivitis but spend 5 minutes detailing their grandmother’s corneal transplant in order to satisfy the family history element of the patient history. Fortunately, these issues have been recognized and certain requirements are being lifted.

New exam coding rules

As of Jan. 1, 2021, the only factors taken into consideration when selecting an E/M code are either complexity of medical decision making or time spent on a patient case. Specific patient history and exam elements are no longer required to justify codes. This removes a significant burden off of the billing practitioner to make sure enough information has been documented, even if it may be unnecessary for treating the patient appropriately. However, the responsibility of the practitioner to understand how both medical decision making and time are used to calculate exam codes is critical.

Complexity of Medical Decision Making

Of the 3 elements that are currently used to calculate exam codes, medical decision making is the most complicated. While most practitioners are familiar with what goes into determining what level a visit is, it will need to become second nature under the new system. Complexity of the medical decision is broken down into three categories:

  • Number of diagnoses or management options
  • Amount of complexity of data reviewed
  • Risk of complication, morbidity and/or mortality

In order to justify using an exam code, two of the three categories must meet the same level of complexity. For example, if the number of diagnoses for a patient encounter is considered highly complex, but the amount of data reviewed and risk of complication is considered low complexity, the practitioner would only be able to apply the exam code for a low level exam. However, if the number of diagnoses and risk of complication are both highly complex, then a high level code can be applied.

Number of diagnoses or management options

This is the most straightforward of the 3 elements. Based on the number of diagnoses addressed at the visit and the complexity of those issues, it’s relatively easy to decide which level your exam meets.

For example, if a glaucoma patient is in for an IOP check and everything looks good, your evaluation of 1 chronic stable condition would be considered low complexity and equate to either a 99203 or 99213 code. It’s important to note that in the current coding system a good rule of thumb was that documentation necessary for a new patient level 3 (99203) code was the same as an established patient level 4 (99214).

This is no longer the case in the new system.

Back to our glaucoma suspect. If the same patient came in for an IOP check and the IOP was not within control, suggesting progression, the level of complexity would increase to moderate and equal either a 99204 or 99214 code. The table below details the requirements for the 2 more commonly used exam levels for eye care providers.

Exam Code Level of Decision Making # of diagnosis or management options
Extended Problem Focused (99203 or 99213) Low
  • 1 – Stable, Chronic (AMD, GlX, etc) OR
  • 1 – Acute Illness, Uncomplicated (conjunctivitis)
  • Detailed (99204 or 99214) Moderate
  • 1 – Unstable Chronic (progressing AMD, glaucoma, etc.) OR
  • 2 – Stable Chronic OR
  • 1 – acute illness, complicated (diplopia due to TBI) OR
  • 1 – acute illness with uncertain prognosis (Retinal tear)
  • Amount of complexity of data reviewed

    For eye care providers, this category will likely be at a lower level than that of diagnoses and risk. Often, we are not ordering a large amount of diagnostic tests that need to be reviewed. That said, there are situations where making sure the data review category is important. When calculating this category it’s important to remember that you cannot count any test interpretations you’ve done and reported separately.

    For example, if a patient was in the office for macular OCT to track macular degeneration progression, your review of previous chart notes and previous OCTs would count toward the amount of data reviewed but the OCT performed and interpreted by you that day would not because you are already being paid for your interpretation through submission of the of the 92134 procedure code. Additionally, making sure that you document your review of previous notes and tests is essential to meeting qualification in this category. Again the table below lists the requirements for low and moderate levels of data review.

    Exam Code Level of Decision Making # of diagnosis or management options
    Extended Problem Focused (99203 or 99213) Low Any combination of 2 from the following:
  • Review of prior external note(s) from each unique source (review of previous chart note)
  • Review of the result(s) of each unique test (review of topography, OCT, HVF)
  • Ordering of each unique test (topo, OCT, HVF)
  • OR Assessment requiring an independent historian(s) (spouse, child, parent, etc.)

    Detailed (99204 or 99214) Moderate Any combination of 3 from the following:
  • Review of prior external note(s) from each unique source (review of previous chart note)
  • Review of the result(s) of each unique test (review of topography, OCT, HVF)
  • Ordering of each unique test (topo, OCT, HVF)
  • Assessment requiring an independent historian(s) (spouse, child, parent, etc.)
  • OR Independent interpretation of a test performed by another physician/other qualified health care professional (interpretation of visual field from previous doctor)

    OR Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (Referral to specialist)

    Risk of complication, morbidity and/or mortality

    Risk of complication for the majority of primary care ODs will come down to medications used. The simple rule of thumb to remember is that if over-the-counter meds are recommended for treatment, the complexity is low while the use of prescription meds for treatment is considered moderate complexity. Management with surgery and the associated complexity levels are detailed in the table below.

    Exam Code Level of Decision Making # of diagnosis or management options
    Extended Problem Focused (99203 or 99213) Low OTC Medications OR Minor surgery without risk factors
    Detailed (99204 or 99214) Moderate
  • Prescription medication OR
  • Minor surgery with identified risk factors OR
  • Major surgery without risk factors OR
  • Risk of death or vision loss (Technically high)
  • As you can see, determining the level of complexity for medical decision making can get complicated, but the more you do it, the more intuitive it will become. It will be rare that you do so little during an exam that you only qualify for level 2. Most straight forward acute issues will be level 3. Once you start addressing multiple diagnoses and giving drug prescriptions, you can code a level 4 exam. Level 5 exams will be relatively few and far between for many docs, but not absent. Just make sure your documentation qualifies to meet the standards before submitting a level 5 code. Level 5 code requirements can be accessed from the CMS website.


    The new way to determine exam code level is by calculating time spent on a patient case. This calculation not only includes face to face time with the patient, but also the time it takes to review their chart information. Here is a list of activities that count toward the total time:

    • preparing to see the patient (eg, review of tests)
    • obtaining and/or reviewing separately obtained history
    • performing a medically appropriate examination and/or evaluation
    • counseling and educating the patient/family/caregiver
    • ordering medications, tests, or procedures
    • referring and communicating with other health care professionals (when not separately reported)
    • documenting clinical information in the electronic or other health record
    • independently interpreting results*
    • communicating results to the patient/family/caregiver ▪ care coordination (not separately reported)

    *Again, if you’re billing a separate procedure code for a test you’ve done, you cannot count the time taken to interpret that test to the total time. I.e. if you spend 10 minutes interpreting a visual field that you bill for that day, you can not apply it to the time total.

    Exam Code Time requirements
    99202 15-29 minutes
    99202 15-29 minutes
    99203 30-44 minutes
    99204 45-59 minutes
    99205 60-75 minutes
    99212 110-19 minutes
    99213 20-29 minutes
    99214 30-39 minutes
    99215 40-54minutes


    We should be looking forward to the new year and a more simple coding system. It will give us the opportunity to base our patient history and physical exam on what is necessary to diagnose and treat the patient not on making sure all the boxes in our EHR are checked. Here’s to more time spent helping our patients and less time staring at our computer screens.

    About Steven Turpin, OD

    Newest member of Cascadia Eye, an OD/MD group practice in Washington. Currently building a specialty lens practice from the ground up. Myopia control and contact lens design are my guilty pleasures.

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