Internal Medicine, coded right.

Use 99213 for a stable established outpatient with one or two minor or stable problems, simple data review, and low-risk management. Typical patterns: routine refill of a stable chronic medication, follow-up on a single well-controlled chronic disease, simple URI evaluation, or a stable hypertension recheck with no medication change. The 2021 MDM rubric requires low complexity on two of three elements (Problems Addressed, Data Reviewed, Risk). Time-based alternative is 20 to 29 minutes of total physician or QHP time on the date of the encounter. Pick the method that supports the strongest note: if the encounter clearly reflects low-complexity MDM, code by MDM and skip a time statement. Avoid the temptation to inflate to 99214 without a moderate-complexity MDM element.

99214 is the workhorse of primary care and most outpatient subspecialties. Use it when at least one of these is true: two or more chronic problems with progression, treatment changes, or side effects; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; or prescription drug management at any complexity. Prescription drug management on its own satisfies the moderate-risk element, which is why straightforward chronic disease follow-ups with a med adjustment routinely clear the 99214 bar. Time-based alternative is 30 to 39 minutes of total time on the date of the encounter. Pick the method that supports the strongest note: encounters with prescription changes are usually cleaner under MDM; encounters with extensive counseling or care coordination are usually cleaner under time.

Use 99215 when the encounter genuinely required high-complexity decision-making: severe exacerbation or decompensation of a chronic illness, an acute or chronic illness or injury that poses a threat to life or bodily function, decision regarding hospitalization, drug therapy requiring intensive monitoring for toxicity, or extensive comorbidity management driving a high-risk decision. Real examples: a CHF patient with new bilateral leg edema and dyspnea where you considered emergency admission; a new-onset AFib with RVR you elected to manage outpatient with same-day rate-control titration; an oncology patient with febrile neutropenia. Time-based alternative is 40 to 54 minutes of total time on the date of the encounter.

99204 is the default code for most new-patient outpatient encounters in primary care and outpatient subspecialty practice. Use it for a new patient with at least one of: two or more chronic problems with progression or treatment changes; one undiagnosed new problem with uncertain prognosis; prescription drug management. Common patterns: new patient establishing primary care with multiple chronic comorbidities; new endocrinology consult for poorly controlled T2DM; new cardiology consult for chest pain and an abnormal stress test result. Prescription drug management satisfies moderate risk on its own, which makes 99204 the right code for the vast majority of new-patient continuity encounters. Time-based alternative is 45 to 59 minutes of total time on the date of the encounter.

Use 99205 for a new patient with severe, decompensated, or high-acuity disease, or for complex consult-style new-patient encounters where decisions about hospitalization, major surgery, drug therapy requiring intensive monitoring, or de-escalation of care are made. Real examples: a new patient referred for severe pulmonary hypertension where right-heart catheterization is planned; a new oncology consult for newly-diagnosed metastatic disease where systemic therapy is initiated; a new patient with decompensated heart failure where admission is considered. Time-based alternative is 60 to 74 minutes of total time on the date of the encounter. Beyond 75 minutes, add 99417 (commercial) or G0316 (Medicare) in 15-minute increments.

G2211 is the continuity add-on. Append it to an office E/M (99202 through 99215) under one of two conditions: you are the continuing focal point for all of the patient's health care (the primary-care framing), OR you are the ongoing care provider for a patient's single serious condition or a complex condition (the subspecialty framing). Common eligible scenarios: a routine primary care follow-up for chronic disease management; an endocrinology continuity visit for diabetes; an oncology survivorship visit; a rheumatology disease-modifying-medication monitoring visit; a nephrology follow-up for CKD progression. Ineligible scenarios: one-time consults, urgent care visits, hospital follow-up where you are not the longitudinal provider, and visits where modifier 25 is appended to the primary E/M (explicitly prohibited).

99497 captures the time spent in a structured conversation about advance directives, healthcare proxy designation, code status, MOLST or POLST forms, hospice eligibility, and goals of care. The patient must be present at the start of the conversation unless the entire visit is with a designated surrogate (which is independently billable but requires explicit documentation). Common scenarios: ACP as a same-day add-on to an AWV (cost-share is waived with modifier 33); ACP at a primary-care continuity visit for a patient with advanced chronic disease; ACP at an oncology visit for a patient at end of treatment options; ACP during a geriatric assessment.

G0444 is the Medicare preventive code for annual depression screening using a validated instrument. Most commonly billed at the AWV (G0438 or G0439) but can stand alone at a problem-oriented visit (append modifier 33 on G0444 to keep it at the preventive rate). Validated tools recognized for billing: PHQ-2 (2-item screen), PHQ-9 (standard 9-item severity scale), Geriatric Depression Scale, Edinburgh Postnatal Depression Scale, Beck Depression Inventory. The most common primary-care workflow is PHQ-2 as the initial screen, followed by PHQ-9 for severity when the PHQ-2 is positive. The score must be documented numerically; a generic statement like "depression screen negative" without a number will fail audit. Annual frequency only: once per 365 days per beneficiary. Use ICD-10 Z13.31 (general adult depression screening) or Z13.32 (maternal depression screening) on the claim.

G0537 captures an annual ASCVD risk calculation plus counseling for patients without established atherosclerotic cardiovascular disease. Use the ACC/AHA Pooled Cohort Equations (PCE) or an equivalent validated tool to compute the 10-year ASCVD risk percentage. The code is for primary prevention only: patients with known coronary artery disease, prior MI, prior stroke, peripheral artery disease, or any documented ASCVD do not qualify. Most natural pairing is with G0438 or G0439 (AWV), but G0537 can also be billed at a problem-oriented visit. Counseling must address one or more modifiable risk factors: hypertension, dyslipidemia, smoking, diabetes, weight, physical activity, or diet. Once per 12 months. ICD-10: Z13.6 (cardiovascular disorder screening). G0538 is the same-day add-on for additional 15-minute increments of high-intensity behavioral counseling (rarely used in primary care; more relevant in cardiology or weight-management practices).

Use 99406 for any encounter where you spent 3 to 10 minutes counseling a current tobacco user on cessation. The 5 A's framework (Ask, Advise, Assess, Assist, Arrange) is the documentation backbone; you do not need all five at every visit but document the ones that occurred. Common settings: a hypertensive smoker at a primary-care follow-up where you advised cessation and discussed pharmacotherapy options; a COPD patient at a pulmonology visit where you assessed readiness and prescribed varenicline; a cardiac patient post-MI where you arranged a referral to a state quitline. The patient must be a current tobacco user (not former). For relapse prevention in an ex-smoker, the work is part of the E/M and is not separately billable as 99406. Time must be documented separately from E/M time; if your E/M counted time toward the 30 to 39 minute 99214 threshold, you cannot also count the cessation minutes toward 99406. The time must be carved out.