E/M coding mistakes 2025

Evaluation and management (E/M) coding is the bread and butter of most medical practices. It’s the engine that keeps the revenue cycle moving! But let’s be honest, it can also be a little tricky. Even with the major updates we saw a few years back, we are still seeing some persistent errors popping up in 2025. And these aren’t just tiny typos; these are mistakes that can lead to lost revenue, audits, and headaches you definitely don’t need.

Why does this matter so much? Because accurate E/M coding ensures you get paid for the hard work you do! It reflects the true complexity of the patient’s condition and the medical decision-making involved. When errors slip through, practices lose money they’ve rightfully earned, or worse, face penalties for overcoding.

So, grab a coffee (or tea!), and let’s dive into the 10 most common E/M coding mistakes 2025 we’re seeing right now, and more importantly, how you can fix them to keep your practice thriving!

1. Incorrect Level of Service Coding

This is the big one! Choosing the wrong level of service is like trying to fit a square peg in a round hole; it just doesn’t work. Many providers default to a “middle of the road” code (like a 99213 or 99214) because it feels safe. But “safe” isn’t always accurate!

The correct code needs to match the specific documentation requirements for that encounter. If you consistently undercode, you are leaving money on the table. If you overcode without the backup, you are waving a red flag at auditors. The goal is always to code based on the actual medical decision-making (MDM) or time spent.

2. Downcoding or Upcoding

Speaking of levels, let’s talk about the dreaded upcoding and downcoding. Upcoding happens when a claim is submitted for a higher level of service than what was supported by documentation (yikes!). Downcoding is the opposite, billing for a lower level than the service provided, often out of fear of an audit.

Both are dangerous! Upcoding is fraud (even if unintentional), and downcoding artificially lowers your practice’s value. You want to be like Goldilocks—finding the code that is just right. Tools from organizations like the American Medical Association AMA can help clarify these boundaries.

3. Insufficient Documentation

We can’t say this enough: If it wasn’t documented, it wasn’t done! This is the golden rule of medical coding. You might have performed a high complexity exam and spent 45 minutes counselling the patient, but if the note only says “Patient doing well, continue meds,” you can’t bill for that high-level service.

Your documentation needs to tell the full story. It must clearly support the complexity of problems addressed and the risk involved. Thorough notes are your best defence and your best friend!

4. Not Using Modifiers Correctly

Modifiers can be confusing, right? They are these little two-digit additions that change the meaning of a CPT code, and using them wrong is a classic E/M coding mistake. For example, Modifier 25 is frequently misused. It’s used to report a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.

If you slap a Modifier 25 on every office visit that includes a minor procedure without proper documentation to separate the two, payers will notice. Check out resources on aapc.com for great guides on modifier usage!

5. Ignoring Payer-Specific Guidelines

Here’s a frustrating truth: Not all payers play by the same rules. While many follow the Centers for Medicare and Medicaid guidelines, private payers might have their own twists on documentation or coverage.

Ignoring these specific rules is a fast track to denials. It’s crucial to have your billing team stay on top of the major payer policies. Websites like billingfreedom.com often have great insights into navigating these payer mazes.

6. Lack of Understanding of Time-Based Coding

Remember when we shifted to allowing code selection based on total time spent? It was a game-changer! But people are still getting tripped up here. Time-based coding isn’t just about the face-to-face time anymore; it includes total time spent on the date of the encounter.

This includes preparing to see the patient (reviewing tests), obtaining history, performing the exam, counselling, and documenting the clinical information in the electronic health record. If you aren’t tracking all that non-face-to-face time, you might be undercoding a complex visit!

7. Failure to Document Medical Necessity

Medical necessity is the overarching criterion for payment. It doesn’t matter how detailed your note is; if the service wasn’t medically necessary, it won’t be paid.

Common E/M coding mistakes 2025 involve cloning notes where the medical necessity isn’t clear for today’s visit. Why is the patient here now? Why do they need this level of care? Make sure the “why” is as clear as the “what.”

8. Not Staying Updated with Coding Changes

The only constant in life (and medical coding) is change! Procedural terminology and guidelines evolve. If your practice is using cheat sheets from 2022, you are likely making errors.

For instance, the rules for split/shared visits or telemedicine evaluation and management have seen significant shifts. You have to stay plugged into the news. Sites like histalk2.com or general news aggregators like bing.com and yahoo.com can actually be great for catching headlines about major healthcare policy shifts.

9. Inadequate Training for Staff

Your staff helps you win! But if they aren’t trained properly, errors will happen. This applies to everyone, from the front desk (getting demographics right) to the providers (documenting right) to the coders (selecting the code).

Regular training sessions are vital. It keeps everyone on the same page and reinforces best practices. Consider checking out prombs.com or thenexusio.com for industry discussions and training tips.

10. Not Utilizing Technology Solutions

Finally, are you still doing everything manually? In 2025, that’s a tough road to travel. There are amazing AI and automation tools out there that can audit your notes in real time or suggest the correct code based on documentation.

Companies like exdionhealth.com and nym.health are doing incredible work with autonomous coding and revenue integrity. Even search tools like ithy.com or viesearch.com can help your staff find answers quickly. Don’t fear the tech, embrace it to catch those E/M coding mistakes 2025 before they go out the door!

Let’s Get Coding Right!

We know E/M coding mistakes 2025 can feel like a maze, but avoiding these common pitfalls will make a massive difference in your practice’s health. By focusing on accurate documentation, understanding the nuances of time vs. MDM, and leveraging modern technology, you can ensure you get paid properly for the care you provide.

Don’t let these mistakes drag you down! Take a look at your current processes, maybe run a little internal audit, and see where you can tighten things up. Your revenue cycle (and your peace of mind) will thank you!