Office visit level: time or medical decision making?
Before you sign an office visit, check which method supports the level: your documented time or the decisions you made. More note text is not the test.
An office visit can be busy without being a high-level visit. The opposite can also be true: a short note may describe a consequential decision. Before choosing a level, decide whether medical decision making (MDM) or total time on the date of the encounter supports it. Then make sure the record tells the same story.
This is a check for the clinician and biller, not a reason to chase a higher code. The right level can move up or down.
If you use MDM
Read the assessment and plan as if you did not attend the visit. Can you see the problems addressed, the information considered, and the management decisions made? A problem list pasted into the note does not, by itself, explain today's decisions.
The note should be specific about what changed or stayed the same and why. If a medication was considered but not changed, say why when that decision matters. If a test result changed the plan, connect the result to the plan. The MDM framework has its own criteria; a long history and exam do not substitute for them.
If you use time
Record the total qualifying time for the date of the encounter or the start and stop times. Do not infer time from the length of the note or count work on another day. Check the applicable code's time threshold and qualifying activities before the claim goes out.
CMS says the full time must be furnished when time selects the visit level. The time written in the chart should be the time used to support that choice, not a generic template value.
The two-minute sign-off check
- What was the reason for the visit? Make it clear in the chart.
- Which method supports the selected level, MDM or time?
- If MDM, does the assessment and plan show the decisions made today?
- If time, is qualifying total time documented for today?
- Would a lower level better reflect the service? Change it if so.
Cortex Lens can point to a possible documentation or coding mismatch while the chart is open. It does not change the note or choose the level for you. The clinician and billing team make that call.
Source: CMS, Evaluation and Management Services, May 2026, pages 23–24. CMS states that medical necessity is primary, most E/M visit levels use MDM or time, history and examination do not select the level, and time-based billing needs documented time.