A complete reference guide for physicians and practice managers. Five levels, clearly explained, including the 2021 AMA Medical Decision Making criteria, MDM tables, time thresholds, and real clinical examples for each level.
Use the level buttons below to jump directly to the E/M code range you want to review. Each level card breaks down the visit type, MDM requirements, time thresholds, and clinical examples so you can compare levels without scrolling through the full page.
1
Pick a level
Click a Level 1 through Level 5 button to jump to that section instantly.
2
Open the card
Select the level card to view the MDM criteria, time range, and example scenarios.
3
Compare criteria
Match at least two MDM elements or use total time when time is the basis for code selection.
4
Expand all
Use Expand all when you want to compare every level side by side.
Tip: Start with the patient type and likely visit complexity, then confirm the final level against documented MDM or total time. This guide supports review, but final code selection should follow your practice policy and payer requirements.
Bookmarked levels:
Presenting problem
Minimal
May not require the presence of a physician or other qualified health professional
Time (established)
1–9 minutes
Total time on the date of encounter
Key characteristics
99211 is the only E/M code that does not require a physician or NPP - a nurse or medical assistant may provide the service
A physician must supervise but does not need to be present in the room or in the building in some circumstances
Documentation must support the level - blood pressure check, prescription refill pickup, routine injection, or vaccine administration
No MDM table applies - the code is based on the minimal nature of the presenting problem
New patients do not have a Level 1 equivalent - 99201 was permanently deleted in the 2021 AMA E/M revisions
A nurse administers a scheduled allergy injection to an established patient. Vital signs are documented. The physician is available in the office but does not participate in the visit. Documented time is 5 minutes.
MDM complexity
Straightforward
Minimal problems, minimal or no data, minimal risk
Time
New: 15–29 min · Est: 10–19 min
Total time on the date of encounter
MDM table - straightforward (must meet 2 of 3 elements)
Element
Requirement
Problems
1 self-limited or minor problem
Data reviewed
Minimal or none - no external records, no independent interpretation required
Risk
Minimal risk - OTC drug management, minor surgery with no identified risk factors
Key characteristics
Typically a single acute, uncomplicated problem: URI, minor laceration, conjunctivitis, or prescription refill for a stable, unchanging chronic condition
Minimal or no data review required - no labs ordered, no imaging reviewed, no external records consulted
Treatment options are straightforward - OTC medications, rest, or a simple prescription with no monitoring required
This level is one of the most commonly over-coded - many visits billed as Level 3 (99214) actually meet only Level 2 criteria on the MDM elements
The 2021 AMA revisions eliminated history and physical exam as billing criteria - a thorough exam does not elevate the level; only MDM and time do
Clinical example
Established patient presents with acute sinusitis, no comorbidities, no prior treatment. Physician prescribes amoxicillin. No labs ordered, no imaging reviewed, no external records consulted. One self-limited problem with minimal MDM. Documents as 12 minutes total time.
2 or more self-limited problems; OR 1 stable chronic illness; OR 1 acute uncomplicated illness or injury
Data reviewed
Limited - review of prior external notes; OR ordering of tests; OR independent interpretation of a result from a prior test
Risk
Low - prescription drug management; OR minor surgery with identified risk factors
Key characteristics
99214 is statistically the most commonly billed established patient code and is frequently scrutinized by payers and auditors
The “2 of 3” MDM rule: a visit qualifies at this level if it meets at least two of the three MDM elements - it does not need to meet all three
A single stable chronic condition being managed with a prescription drug alone meets both the Problems element (1 stable chronic illness) and the Risk element (prescription drug management) - two of three are met
The 2021 AMA revisions eliminated history and physical exam from the billing criteria entirely - a detailed exam does not raise the level if MDM doesn't support it
Common documentation error: physicians document a full exam and thorough history but fail to explicitly document the MDM reasoning - the audit will fail on MDM, not exam
Dragon Copilot’s “Prepare My Note” feature can automatically append MDM complexity notes, ICD-10 codes, and E/M level suggestions to each encounter
Clinical example
Established patient with well-controlled hypertension and type 2 diabetes presents for routine follow-up. Labs from prior visit reviewed in chart. Medications continued without change. Two stable chronic conditions (problems element met). Review of prior lab results (data element met). Two of three MDM elements satisfied - qualifies as Low MDM / Level 3.
MDM complexity
Moderate
Must meet 2 of 3 MDM elements at the moderate level
1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; OR 2 or more stable chronic illnesses; OR 1 undiagnosed new problem with uncertain prognosis; OR 1 acute illness with systemic symptoms; OR 1 acute complicated injury
Data reviewed
Moderate - review of external records AND independent interpretation of a test AND discussion with treating/consulting physician; OR use of an independent historian (family member, caregiver)
Risk
Moderate - prescription drug management requiring monitoring; OR minor surgery with identified risk factors; OR elective major surgery without risk factors; OR diagnosis or treatment significantly limited by social determinants of health (SDOH)
Level 3 vs Level 4 - the distinctions that matter most
The core distinction on problems: Level 3 requires 1 stable chronic illness. Level 4 requires either 2 or more stable chronic illnesses, OR 1 chronic illness that is in exacerbation, progressing, or causing treatment side effects
A single well-controlled diabetic patient on metformin does not meet the Level 4 problems threshold - that is one stable chronic illness, which is Level 3
A diabetic patient whose A1c has risen from 7.2 to 8.9 despite medication changes qualifies for Level 4 on problems alone - the condition is progressing
Social determinants of health (SDOH) were added as a Moderate risk element - when homelessness, food insecurity, or inability to afford medications significantly limits your ability to diagnose or treat, this supports Level 4 risk
Most audit disputes involve Level 4 - the key is documenting the MDM reasoning explicitly in the note body, not just listing diagnoses
Prescription drug management “requiring monitoring” (Moderate risk) includes drugs like warfarin, methotrexate, lithium, immunosuppressants, and any agent requiring lab monitoring
Clinical example
Established patient with type 2 diabetes and hypertension. A1c has risen from 7.1 to 8.6 over the past two visits despite medication adjustments. Physician reviews an outside endocrinology note, adjusts insulin dosing, and orders repeat HbA1c and CMP in 6 weeks. Problems: chronic illness with progression. Data: external record reviewed. Risk: prescription drug management with monitoring. All three MDM elements met at Moderate - Level 4.
MDM complexity
High
Must meet 2 of 3 MDM elements at the high level
Time
New: 60–74 min · Est: 40–54 min
Total time on the date of encounter
MDM table - high complexity (must meet 2 of 3 elements)
Element
Requirement
Problems
1 or more chronic illnesses with severe exacerbation, progression, or treatment side effects; OR 1 acute or chronic illness or injury that poses a threat to life or bodily function
Data reviewed
Extensive - must meet 3 or more of: review of prior external notes, independent interpretation of test results, direct discussion with treating or consulting physician, use of independent historian
Risk
High - drug therapy requiring intensive monitoring for toxicity; OR decision regarding hospitalization; OR decision not to resuscitate or to de-escalate care because of poor prognosis
Key characteristics
Level 5 is statistically under-coded - many physicians who legitimately qualify for it bill at Level 4 out of audit concern, leaving significant revenue on the table
A threat to life or bodily function on the problems element includes: new stroke, pulmonary embolism, sepsis, acute MI, new cancer diagnosis, severe hemorrhage, acute renal failure, anaphylaxis, and similar presentations
“Drug therapy requiring intensive monitoring for toxicity” explicitly includes warfarin, lithium, clozapine, methotrexate, digoxin, chemotherapy agents, and aminoglycosides
A goals-of-care or DNR discussion - even without a terminal diagnosis - meets the High risk element when documented
The decision whether to hospitalize a patient, even if the patient is ultimately sent home, qualifies for High risk if the deliberation is documented
Documentation must explicitly reflect the severity and the complexity of the clinical decision - the ICD-10 code alone is not sufficient; the note must describe why this case was high complexity
Dragon Copilot’s ambient documentation captures the clinical reasoning during the encounter, making it significantly easier to produce the Level 5 documentation that auditors require
Clinical example
New patient presents with three weeks of progressive dyspnea and pleuritic chest pain. Physician reviews prior chest CT from outside hospital, interprets in-office EKG, and calls the patient’s pulmonologist to discuss. Working differential includes PE. Physician weighs immediate hospitalization against outpatient CTA with anticoagulation bridge. Decision made to send directly to ED. Problems: acute illness posing possible threat to life. Data: three elements met (external record, independent test interpretation, physician discussion). Risk: hospitalization decision. All three MDM elements at High - Level 5.
About this resource
This guide was written for physicians, nurse practitioners, physician assistants, and practice managers who need a clear, practical reference for E/M coding decisions at the point of care. It reflects the 2021 AMA Evaluation and Management coding revisions, which eliminated history and physical examination as billing criteria and established Medical Decision Making (MDM) and total encounter time as the sole determinants of E/M level.
The five office and outpatient visit levels covered here are: Level 1 (99211), Level 2 (99202 / 99213), Level 3 (99203 / 99214), Level 4 (99204 / 99215), and Level 5 (99205 / 99215). Each level is explained with its MDM complexity threshold, time alternative, and a real clinical example.
The most commonly misunderstood distinction in outpatient coding is Level 3 versus Level 4 - specifically the difference between one stable chronic illness (Level 3) and two or more stable chronic illnesses, or one chronic illness with exacerbation or progression (Level 4). This guide addresses that distinction directly with examples.
This resource is published by Doug Lister, Microsoft Cloud Solutions Partner and owner of Advanced Medical of Georgia, a national provider of AI-powered clinical documentation solutions including Microsoft Dragon Copilot and Dragon Medical One. Dragon Copilot's ambient documentation and Prepare My Note features support accurate E/M level capture by documenting MDM elements during the clinical encounter. For a demo, contact Doug Lister at 404-457-9592 or
CONTACT US.
Reference note: This guide reflects the 2021 AMA E/M coding revisions for office and outpatient visits, updated through 2025. Time ranges reflect total physician time on the date of the encounter, including face-to-face and non-face-to-face activities such as reviewing records, ordering tests, and documenting notes. This is a clinical reference tool - coding decisions for specific encounters should be reviewed with a certified professional coder (CPC) or compliance officer, and confirmed against your specific payer contracts and documentation requirements.
