Evaluation and Management (E&M) codes are the bread and butter of general practice revenue. But persistent changes to documentation requirements, combined with aggressive payer downcoding, mean that many practices are billing at the wrong level - either leaving money on the table through undercoding or risking audits through overcoding. Here's where things stand in 2025.
The Shift to Medical Decision-Making
Since the 2021 E&M overhaul, code level selection has been based primarily on medical decision-making (MDM) complexity - not the old '95/97 guidelines' that counted exam elements. In 2025, this framework is fully established, but many practices still document as if exam bullets determine the code level.
If your providers are spending time documenting 10 systems review instead of focusing on the complexity of their decision-making, they're doing extra work for no billing benefit.
Understanding the MDM Table
MDM is assessed across three elements: number and complexity of problems addressed, amount and complexity of data reviewed, and risk of complications.
To qualify for a given E&M level, the provider must meet two of the three MDM elements. Common mistake: documenting extensively on data reviewed but not clearly articulating the complexity of the problems addressed.
Payer Downcoding: Why It Happens
Payers regularly downcode E&M claims - paying at a lower level than billed. This happens when documentation doesn't clearly support the billed level, when the diagnosis doesn't match the expected complexity, or when automated payer algorithms flag the code as an outlier.
Practices that consistently bill 99214 or 99215 without strong MDM documentation are prime targets for downcoding.
Undercoding: The Silent Revenue Leak
Many providers habitually undercode to avoid audit risk. They bill 99213 for visits that clearly support 99214 based on MDM complexity. Over thousands of visits, this conservative billing costs practices significant revenue.
The difference between 99213 and 99214 is roughly $40–60 per visit. For a practice seeing 30 patients per day, that's up to $450,000 in annual revenue if just half those visits are undercoded by one level.
How to Ensure Accurate E&M Coding
1. Train providers on the MDM framework - not the old exam-based system. 2. Audit a sample of charts monthly to check for systematic under- or overcoding. 3. Use coding decision support tools that analyze documentation in real time. 4. Compare your code distribution to specialty benchmarks - outliers in either direction signal a problem. 5. Appeal payer downcodes with clear MDM documentation.
How Pono Helps
Pono's E&M coding audit compares your practice's code distribution to specialty benchmarks, identifies systematic undercoding, and flags documentation gaps before claims go out.
Want to find out if your practice is leaving E&M revenue on the table?
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