Leveling a Visit for an Acute Uncomplicated Illness

CodeCast | Medical Billing and Coding Insights

The September 2025 issue of CPT® Assistant raised important questions about how to appropriately level an evaluation and management (E/M) encounter when the presenting problem is an acute, uncomplicated illness or injury. A growing number of providers have been assigning Level 4 codes simply because an antibiotic was prescribed.

However, this approach may not be accurate when considering the full scope of the encounter and its required documentation elements.

Terry examines this trend and explains why many payers have responded by implementing automatic down-coding policies to address potential overcoding.

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