IM Visit Coder

1Patient & payer

Patient

Insurance

Plan

Edit what each plan pays

Saved on this phone only. Ask your billing team, then update these.

2Visit type

How was the visit done?

Where was the patient?

How your clinic bills Medicaid annuals

Contact within 2 business days of discharge?

Phone, portal or in person; clinical staff can make it. Two documented attempts also count.

Today's visit after discharge

Medications reconciled by today?

Medicare annual visit

Age

Also managed a real problem? (adds a -25 visit)

Preventive add-ons done today (Medicare; tap all that apply)

3Problems addressed

Count every problem you addressed. Mix freely, e.g. 1 simple + 1 complicated, or 1 stable + 1 worsening chronic.

Acute

Minor / self-limitedGoes away on its own: cold, insect bite, mild sunburn

Simple acuteUncomplicated, low risk: cystitis, pharyngitis, sinusitis, URI, ankle sprain, otitis media

Stable acuteAlready treated, improving but not resolved: pneumonia on day 7 of antibiotics

Complicated acuteSystemic symptoms or complicated injury: pyelonephritis, pneumonia, cellulitis with fever, fall with head strike

Chronic

Stable chronicAt treatment goal: controlled HTN, diabetes at A1c goal, stable hypothyroidism

Worsening chronicNot at goal, progressing, or treatment side effects: uncontrolled HTN, A1c rising, statin myalgia

Severe exacerbationChronic illness with major worsening, may need hospital: CHF with marked fluid overload

Other

Undiagnosed new problemUncertain outcome, needs workup: new breast lump, unexplained weight loss

Threat to life or bodily functionNeeds urgent action: chest pain concerning for ACS, possible stroke, sepsis

What counts? (tips for new coders)

Fever, aches or fatigue alone don't make an illness "complicated" if it's minor and you only treat symptoms. Flu treated with rest and fluids is still simple.
Several simple or stable problems don't add up to Moderate. The only exception is 2 or more stable chronic illnesses.
Count a problem only if you actually evaluated or managed it today. Listing it in the history doesn't count.
A chronic illness is "worsening" when it isn't at its treatment goal, even with no symptoms.

4Data

Unique tests ordered + results reviewed + outside notes reviewed

Count each unique test once. A test you order today is not counted again when you review it next visit.

5Risk of management

6Time & continuity

Your total minutes today

Everything you did on this date: chart prep, visit, orders, notes, coordination. Not staff time.

Ongoing longitudinal care or serious/complex condition? (G2211)

7Procedures & tests done today

Each adds its own wRVU. Minor procedures and injections put modifier 25 on the office visit.

Patient messages & check-ins

MyChart messages the patient starts (99421–99423) and brief phone or video check-ins (98016).

Type

Did the patient start it?

Related office visit in the past 7 days?

Led to an office visit (next 24 h or soonest slot)?

Your total minutes (add up all replies over 7 days)

Monthly care management

Billed once per calendar month, not per visit. Only one program per patient per month.

Program

Who did the work?

Care plan substantially changed this month (moderate/high MDM)?

Minutes this month

Chronic conditions

Qualified Medicare Beneficiary (QMB)?

Cognitive assessment & care plan (99483)

One of the highest-value office codes (3.84 wRVU). Schedule it as its own visit when a cognitive screen is positive. Typically 60 minutes; once per 180 days; no office visit billed the same day.

Daily wRVU goal

Today vs goal

Set a goal to see progress.

Saved only on this phone or computer, in this browser. No patient information is stored: only date, codes and wRVUs. Export now and then as a backup.

Saved visits

Office visits: wRVU and minimum time

Bill the higher of MDM or total time. MDM needs 2 of 3: problems, data, risk.

MDM	New	wRVU	Time	Est.	wRVU	Time
Straightforward	99202	0.93	15	99212	0.70	10
Low	99203	1.60	30	99213	1.30	20
Moderate	99204	2.60	45	99214	1.92	30
High	99205	3.50	60	99215	2.80	40

MDM elements

Level	Problems	Data	Risk
Low	1 stable chronic; 1 acute uncomplicated; 2+ minor	2 of: test ordered, result reviewed, outside note; or independent historian	OTC drugs
Moderate	1 chronic worsening; 2+ stable chronic; undiagnosed new problem; acute with systemic symptoms	1 of: 3 items above (historian counts); own test interpretation; outside discussion	Prescription drug management; SDOH limits care
High	Severe exacerbation; threat to life or bodily function	2 of the 3 moderate categories	Intensive toxicity monitoring; hospitalization; DNR / de-escalation

Annual visits

Payer	Code	When	wRVU
Medicaid / Private	99385 / 99395	18–39, new / est.	1.92 / 1.75
Medicaid / Private	99386 / 99396	40–64, new / est.	2.33 / 1.90
Medicaid / Private	99387 / 99397	65+, new / est.	2.50 / 2.00
Medicare	G0402	IPPE, first 12 months of Part B	2.60
Medicare	G0438	First AWV	2.60
Medicare	G0439	Repeat AWV, yearly	1.92

Medicare does not cover routine physicals (99381–99397). Some Medicare Advantage plans do; check the plan.

Add-ons by payer

Rule	Medicare	IL Medicaid	Private
Annual visit	IPPE / AWV only	99385–99397 + Dx Z00.00 / Z00.01. 1 per 333 days (2nd with new PCP or female exam). Ages 18–20 = Healthy Kids (EPSDT)	99385–99397 + Dx Z00.00 / Z00.01
Annual + problem (-25)	Paid	Managed care: usually paid with -25 (some plans 50%). HFS fee-for-service: one code only	Usually paid; some cut to 50%
G2211 (+0.33)	Paid; OK on -25 with AWV/IPPE since 2025	Not paid; don't bill	Follow-ups only, if the plan pays it. Never with an annual (-25). Not paid by UHC commercial or Ambetter IL
Prolonged (+0.61 / 15 min)	G2212: 99215 at 69 min, 99205 at 89	99417: 55 / 75 min (verify)	99417: 55 / 75 min
AWV extras	ACP 99497-33 (1.50) / 99498 (1.40); G0444 depression (0.18); G0442 alcohol screen (0.18), G0443 counseling (0.60); G0537 ASCVD risk (0.18); G0446 CVD counseling (0.60); G0136 activity & nutrition (0.18); 99406/99407 tobacco (0.24/0.50); G0447 obesity (0.60); G0296 lung screening visit (0.52); G0101 (0.44), Q0091 (0.36)	–	–

Procedures, transitions and monthly codes

Service	Code	wRVU	Key rule
Large / medium / small joint injection	20610 / 20605 / 20600	0.77 / 0.66 / 0.64	-25 on the office visit; no G2211 that day (Medicare)
ECG with interpretation	93000	0.17	No -25 needed
IM/SC injection; vaccine admin	96372; 90471 (+90472)	0.17; 0.17 (+0.15)	Medicare flu/pneumococcal: G0008/G0009 (flat fee). G2211 still allowed with vaccines
TCM, moderate MDM, visit ≤14 days	99495	2.78	Contact within 2 business days; meds reconciled by the visit; once per 30 days
TCM, high MDM, visit ≤7 days	99496	3.79	Same, plus visit within 7 days
Portal messages (7 days)	99421 / 99422 / 99423	0.25 / 0.50 / 0.80	5–10 / 11–20 / 21+ min; patient-started; not tied to a visit in the past 7 days
Phone/video check-in	98016	0.30	5–10 min, established patient
CCM, staff 20 min (+20)	99490 (+99439)	1.00 (+0.70)	2+ chronic conditions; consent; care plan; monthly
CCM, physician 30 min (+30)	99491 (+99437)	1.50 (+1.00)	Your own time
Complex CCM, staff 60 min (+30)	99487 (+99489)	1.81 (+1.00)	Care plan substantially revised
PCM, physician / staff 30 min	99424 / 99426	1.45 / 1.00	One high-risk condition
APCM levels 1 / 2 / 3	G0556 / G0557 / G0558	0.25 / 0.77 / 1.67	Medicare; no time; not with CCM/PCM/TCM same month
Cognitive assessment & care plan	99483	3.84	All 11 elements; once per 180 days

Put this app on your home screen

Open daikonfuji.github.io/im-visit-coder on your phone. Chrome: tap ⋮, then Add to Home screen (or Install app). Firefox: tap ⋮, then Add app to Home screen. It opens full-screen like an app and keeps working without signal after the first visit.

On a computer, the same link shows the codes beside the form.

Sources: CMS 2026 Physician Fee Schedule relative value file; AMA CPT E/M guidelines; CMS CR 13705 (G2211 with modifier 25); Illinois HFS, Meridian, Aetna Better Health IL and Ambetter IL payer notices.