Coding & Documentation
A practical desk reference for office E/M, preventive medicine, and Medicare wellness visits
If you have ever finished charting a patient and stopped to think, “Okay…which code am I supposed to use for this visit?” you are not alone.
This is one of the most common questions I hear from providers, and honestly, it makes sense. Providers go to school to learn how to care for patients. They are not taught every detail of E/M coding, preventive visit codes, Medicare wellness visits, medical decision making, or how all of those pieces fit together. Once they are in practice, however, they are still expected to document visits in a way that accurately reflects the care they provided.
That is why I created a simple, practical tool you can keep beside you while charting—a quick reference for questions such as:
- Is this a 99213 or 99214?
- Which preventive code applies to this patient’s age?
- What is the difference between G0438 and G0439?
- What does “two out of three elements of MDM” actually mean?
Print it, keep it beside your computer, and reach for it when coding questions come up during your workday.
Download the free coding guide (PDF)
First: What Kind of Visit Are You Coding?
Before you can choose the correct code, you have to know which type of service you are dealing with. That is where I see a lot of the confusion start.
A problem-oriented visit is not coded the same way as a preventive physical. A pediatric well-child visit uses a different coding structure than a Medicare Annual Wellness Visit. And something as simple as “patient is here for medication refills” does not automatically tell you whether the visit is a 99213 or 99214.
For office and outpatient E/M services, codes such as 99213, 99214, and 99215 are selected using medical decision making (MDM) or qualifying total time.
Preventive medicine services work differently. Codes 99381–99397 cover preventive services for infants, children, adolescents, and adults, and the office/outpatient MDM changes do not apply to that preventive code family.
Medicare adds another layer because its Initial Preventive Physical Examination and Annual Wellness Visits use their own HCPCS codes rather than the routine preventive medicine code family. CMS instructs providers to use G0402 for the IPPE and G0438/G0439 for Medicare AWVs.
Identifying the type of visit before looking for a code can make the whole process much easier.
What Does “Two Out of Three” Mean in E/M Coding?
This is something providers hear all the time without anyone really explaining what it means.
When an office/outpatient E/M level is selected using medical decision making, MDM is divided into three elements:
- Problems addressed
- Data reviewed and analyzed
- Risk of patient management
The overall MDM level is based on meeting two of those three elements at the required level. That is the structure in the AMA’s MDM table. It can look intimidating at first, but I like to simplify it into three questions:
- What problems did I actually address today?
- What qualifying data did I review, order, or analyze?
- What was the risk involved in the management decisions I made?
Once you start looking at the encounter that way, E/M coding begins to make much more sense. The printable guide turns that concept into a simpler desk reference, including examples showing how the pieces can come together for different E/M levels.
Why Isn’t Every Medication Refill a 99214?
This is a great example of why understanding MDM matters. You may have heard that prescription drug management can support moderate risk. That is true, but it does not mean every visit involving a prescription automatically becomes a 99214.
You are looking at the overall medical decision making and generally need two of the three MDM elements to support the selected level. The AMA uses an educational example involving a patient with hypertension and hyperlipidemia who comes in for medication review. That example supports 99214 because the encounter meets the moderate threshold through two MDM elements—not simply because medication was involved.
That is the difference between memorizing a coding “trick” and understanding why the visit supports the code.
Preventive Visits Can Be Just as Confusing
Then we get into preventive care: pediatric well-child visits, adult preventive exams, new patients, established patients, different codes depending on age—and Medicare’s G0402, G0438, and G0439.
For preventive medicine services, the 99381–99397 code family applies to infants through adults, and the appropriate code depends on factors including the patient’s age and new-versus-established status.
The downloadable reference guide organizes the pediatric and adult preventive codes by age and patient status so you do not have to search for them every time you are charting.
And Then There’s Medicare…
Medicare wellness visits are another area where I see a lot of confusion. The “Welcome to Medicare” visit, first Annual Wellness Visit, and subsequent Annual Wellness Visits are not interchangeable.
CMS identifies:
- G0402 as the Initial Preventive Physical Examination, available during the beneficiary’s first 12 months of Medicare Part B enrollment
- G0438 as the initial Annual Wellness Visit
- G0439 as the subsequent Annual Wellness Visit
CMS also has specific frequency and eligibility requirements for these services, and a Medicare AWV is not simply another name for a routine annual physical.
There can be situations where a patient receives an AWV and the provider performs a significant, separately identifiable, medically necessary problem-oriented E/M service. CMS allows an additional office/outpatient E/M in qualifying circumstances with modifier 25. There are also G2211 considerations when certain Medicare preventive services and a qualifying office/outpatient E/M occur on the same day.
Those are exactly the kinds of details that are hard to keep in your head while seeing patients and finishing charts.
That’s Why I Made Something You Can Actually Keep
I did not want to create another long coding manual that gets downloaded and never opened again. I wanted something practical—something you can print, highlight, write notes on, and grab when you are charting.
The free E/M, Preventive & Wellness Coding Reference Guide includes:
- New and established office/outpatient E/M codes
- A simplified MDM reference table
- An explanation of the two-out-of-three MDM rule
- Real-world examples showing how 99213, 99214, and 99215 can be supported
- Pediatric well-child preventive codes by age
- Adult preventive codes by age
- Medicare G0402, G0438, and G0439
- Preventive/wellness plus problem-oriented E/M reminders
- Common E/M questions providers ask
You do not have to memorize all of this. You just need to know where to find it.
Use it as a quick reference when coding questions come up during your workday.
Download the E/M, Preventive & Wellness guide (PDF)
Primary References
Educational disclaimer: This article and downloadable guide are simplified references provided for educational purposes. They do not replace the current CPT code set, CPT E/M guidelines, CMS guidance, payer policies, benefit verification, or individualized coding review. Coding and coverage requirements can change. CPT is a registered trademark of the American Medical Association.