Notes and checklists for documentation, coding, and RVUs.

This is a memory aid, not coding advice. Always confirm payer-specific rules and the current year’s fee schedule.

See also: Payers and Coverage & Reimbursement Decisions for how reimbursement and medical-necessity policies affect what gets paid.

RVU basics (outpatient & primary care)#

RVUs are assigned per CPT/HCPCS code and drive Medicare payment and many productivity models.

• Components (per code):
  • wRVU (work): clinician time/effort/skill.
  • peRVU (practice expense): staff/overhead; has facility vs non-facility values.
  • mpRVU (malpractice): liability cost.
• Geography: each component is adjusted by local GPCI.
• Payment (Medicare): Allowed = (wRVU*wGPCI + peRVU*peGPCI + mpRVU*mpGPCI) * ConversionFactor.
• Compensation: many groups pay on wRVU only (confirm your contract).

Office/Outpatient E/M in primary care (99202–99215)#

What determines the level#

Since the 2021 E/M changes, office/outpatient E/M level is selected by either:

• MDM (medical decision making), or
• Total time on the date of service (includes chart review, documentation, care coordination; excludes separately reported procedures).

History and exam are documented as medically appropriate (they do not drive the code level).

New vs established (quick reminder)#

• New patient: not seen by you/your group in the last ~3 years (payer definitions vary).
• Established: seen within that window.

Diagnosis “requirements” (how problems affect MDM)#

E/M “diagnosis requirements” are not ICD-10-specific checklists; they’re the problem categories used in the MDM framework (the “Problems Addressed” element).

Common categories you’ll see in outpatient primary care:

• Self-limited/minor (e.g., uncomplicated viral URI).
• Stable chronic illness (e.g., controlled HTN, stable hypothyroidism).
• Acute uncomplicated illness/injury (e.g., cystitis, otitis media without complications).
• Chronic illness with exacerbation/progression/side effects (e.g., COPD flare, diabetes with worsening A1c requiring med changes).
• Acute illness with systemic symptoms (e.g., pneumonia with fever/tachycardia).
• Threat to life or bodily function (rare in routine clinic; e.g., concern for ACS/CVA, severe decompensation).

To count as a “problem addressed,” document what you did about it: assessment, differential as needed, and plan (testing, meds, counseling, follow-up, referral).

MDM (quick outpatient cheat sheet)#

MDM level is based on meeting 2 of 3 elements:

1. Problems addressed
2. Data (tests reviewed/ordered, external records, independent historian, interpretation, discussion)
3. Risk (treatment risk; prescription drug management often drives “moderate”)

Practical anchors in primary care:

• Low MDM: straightforward problems + low-risk management.
• Moderate MDM: multiple chronic problems and/or meaningful escalation; often prescription management.
• High MDM: high-risk clinical decision making (less common in typical clinic visits).

Time ranges (if billing by time)#

Use total clinician time on the date of encounter (payer-specific; confirm your rules):

• New patient: 99202 15–29 min, 99203 30–44, 99204 45–59, 99205 60–74
• Established: 99212 10–19 min, 99213 20–29, 99214 30–39, 99215 40–54

Requirements by code (MDM anchors)#

Use these as “sanity checks” only—final level depends on the full 2-of-3 MDM test or time.

• 99202 / 99212 (straightforward MDM): minor/stable problems, minimal data, minimal risk.
• 99203 / 99213 (low MDM): typically 2+ stable chronic illnesses or 1 acute uncomplicated problem; limited data; low risk.
• 99204 / 99214 (moderate MDM): typically 1+ chronic illness with exacerbation/progression or 2+ stable chronic illnesses; moderate data and/or prescription drug management; moderate risk.
• 99205 / 99215 (high MDM): high-risk decision making (e.g., threat to life/bodily function, decision regarding hospitalization/major morbidity risk); extensive data and/or high-risk management.

Bare-minimum documentation by code (what must be in the note)#

There is no “one weird trick” or diagnosis-only shortcut: E/M levels are supported by what you did (MDM or time). Requirements vary by payer and audits, but the following is a practical minimum.

For any office/outpatient E/M (all levels):

• A coherent note with CC/reason for visit
• The problem(s) addressed today and a clear assessment & plan
• Any data you reviewed/ordered and why it mattered (if applicable)
• The risk/management decisions (med changes, counseling, follow-up, escalation/ED precautions)
• If billing by time: total minutes on the date of service and that time was for E/M work (exclude separately billed procedures)

New patient (99202–99205):

• 99202 (straightforward MDM) or 15–29 min
  • Document at least one minor/self-limited or stable problem + a simple plan; minimal data; minimal risk.
• 99203 (low MDM) or 30–44 min
  • Document problems consistent with low complexity (e.g., acute uncomplicated or 2+ stable chronic) + plan; limited data; low risk.
• 99204 (moderate MDM) or 45–59 min
  • Document why it’s moderate (2 of 3 MDM elements). Most common driver: prescription drug management (start/stop/adjust) with rationale and monitoring/follow-up.
• 99205 (high MDM) or 60–74 min
  • Document high-risk clinical reasoning (2 of 3 MDM elements): severe problem/risk decisions, extensive data, and/or high-risk management with clear justification and safety-netting.

Established patient (99211–99215):

• 99211 (minimal service; time not typically used)
  • Document the service provided and why (should link to an existing plan of care); payer rules vary and some require specific supervision/incident-to conditions.
• 99212 (straightforward MDM) or 10–19 min
  • Straightforward problems + simple plan; minimal data; minimal risk.
• 99213 (low MDM) or 20–29 min
  • Low-complexity problems + plan; limited data; low risk.
• 99214 (moderate MDM) or 30–39 min
  • Document why it’s moderate (2 of 3). Common driver: prescription management (new Rx/adjustment) and/or meaningful workup decisions with follow-up.
• 99215 (high MDM) or 40–54 min
  • Document why it’s high (2 of 3): high-risk condition/decision making and clear escalation/safety-netting.

Add-on code:

• G2211 (Medicare add-on to office/outpatient E/M; payer rules apply)
  • Document why the visit represents ongoing, longitudinal, complex care (e.g., relationship-based continuity, care coordination burden, multiple interacting chronic conditions).
  • Confirm current CMS rules for when it’s allowed/denied (common pitfalls include certain procedure scenarios and modifier -25).

Code → RVU mapping (how to look it up)#

RVU values change by year and (for peRVU) by setting, so this page focuses on how the mapping works.

For each CPT/HCPCS code, look up these fields in the current year’s CMS Physician Fee Schedule Relative Value File:

• work_rvu
• pe_rvu_facility and pe_rvu_nonfacility
• mp_rvu

For typical clinic-based primary care, you’ll usually use non-facility peRVU.

Common outpatient primary care codes to map:

• New patient office/outpatient: 99202 99203 99204 99205
• Established patient office/outpatient: 99211 99212 99213 99214 99215
• (Medicare) Visit complexity add-on: G2211 (payer rules apply; document longitudinal/complex care context)

For G2211, document why the visit is inherently more complex (e.g., longitudinal relationship, care coordination burden, multiple interacting chronic conditions). Medicare restrictions change over time; double-check current CMS guidance (common denials include when the E/M is billed with modifier -25 for a separate procedure).

Table scaffold (fill in annually from the RVU file):

From billed lines to RVUs:

• Per line: line_total_RVU = units * (wRVU + peRVU + mpRVU) (use facility vs non-facility peRVU as appropriate)
• Per day / per clinician: sum line_total_RVU across all billed lines
• wRVU productivity: sum units * wRVU across billed lines

Documentation checklist (E/M)#

• Chief complaint and a clinically coherent note
• Problem list addressed today (don’t count “FYI” conditions)
• Assessment & plan for each addressed problem (including follow-up/return precautions)
• Data you reviewed/ordered (labs/imaging/notes), and what it changed
• Risk: meds started/stopped/adjusted, decision about escalation, safety-netting
• Time (only if billing by time): total minutes + what you did

Pitfalls / reminders#

• Don’t upcode on diagnosis alone: code level comes from MDM or time, not “how serious the ICD-10 looks.”
• Link ICD-10 to what you did: the diagnosis should support medical necessity for tests/meds/procedures.
• Setting matters for peRVU (facility vs non-facility).