Article Reference Code: NAMAS.10.24.2025
5 Steps in Auditing E/M for a Beginner
Written by: Alexis Combs
Most know that Evaluation and Management (E/M) services are some of the most common codes you’ll come across in medical billing and auditing. This guide is all about office and outpatient visits, the bread and butter of E/M coding. Because these codes depend a lot on what’s written in the provider’s notes, they’re often checked by insurance plans, Medicare, and internal review teams.
Whether you’re new to coding, preparing for the CPC exam, or learning on the job, auditing E/M might sound intimidating, and you may feel unsure about how to apply the guidelines, evaluate documentation, or determine if a code was assigned correctly. That’s completely normal.
But don’t worry! This guide breaks down the process into clear, manageable steps so you can build confidence and accuracy when reviewing E/M documentation. By understanding the basics of E/M auditing, you’ll not only improve your coding skills but also contribute to compliance and appropriate reimbursement for healthcare providers. With time and practice, you’ll be able to spot documentation gaps, recognize coding errors, and provide helpful feedback with ease.
Step 1: Categorize the Visit Type
First things first, what type of E/M visit are you looking at? If it’s an office visit, start by checking whether the patient is new or established with the provider. That little detail determines which code range you’ll use. Make sure you’re following the correct E/M guidelines, like the 2021 updates for office visits.
Step 2: Review Medical Necessity and the Chief Complaint
Every visit should have a clear reason, that’s what we call medical necessity. Think of it as the “why” behind the visit. As you read the note, ask yourself: “Can I easily tell why the patient came in and what the provider did about it?”
Medical necessity should be supported by several components of the note: Problems addressed, complexity of each problem and the evaluation of the patient as relevant by the provider. The presenting problem should be addressed in the documentation, meaning it is managed and/or treated, as this begins to show the complexity of the patient. A strong audit starts by making sure the documentation tells a complete and logical story that matches the level of service being billed.
Step 3: Look at the Key Pieces of the Note
Now dive into the note and check what the provider documented. Did they pick the code based on Medical Decision Making (MDM) or Total Time?
“The AMA allows providers to select the level of E/M service based on either Medical Decision Making or total time, whichever is most appropriate for the visit.” – American Medical Association
- If it’s MDM, you’ll look at:
- How many and how complex the problems addressed were
- How much data was reviewed (labs, tests, notes)
- The risk of ongoing treatment or further testing of the patient
- If it’s based on Time, the provider should note the total time they spent with the patient on the day of the visit, and what they were doing during that time, like reviewing labs, talking to the patient, or documenting the visit. The total time should make sense for the level of service chosen.
Step 4: Match the Code to the Documentation
Now take a look, does the note really back up the code that was billed? If it feels a little too high or too low for what’s written, jot it down. You’re not just going through the motions here; you’re making sure the story in the note truly matches the level of care that was provided.
Step 5: Share What You Found (Nicely!)
When you’re done reviewing, put together a friendly summary. Let the provider or team know what went well and what could use a little work. If something wasn’t quite right, explain why and offer a suggestion. Keep it helpful, not critical, everyone’s learning.
Remember: your job isn’t to second-guess the medical decisions made, it’s to help ensure the documentation accurately supports the code selected. Think of yourself as a translator between clinical care and coding rules, helping providers get properly reimbursed for the care they deliver.
Ways to Improve Your E/M Skills
Just like any skill, auditing gets easier the more you do it. Here are a few ways to keep growing:
- Take a Bootcamp: NAMAS offers E/M bootcamps that go through real-life examples and help you practice reading notes and picking codes.
- Practice Often: Look at real (just make sure they’re redated and de-identified) or sample notes and try auditing them. Then check your answers with a mentor or answer key.
- Join a Study Group or Forum: Talking with others in the field helps you learn faster and stay updated.
- Keep Up with Guideline Changes: E/M rules can change every year, so keep an eye on updates from CMS or the AMA.
Auditing office visits doesn’t have to be overwhelming. Like learning any new skill, it takes time, patience, and practice. By taking it one step at a time, you’ll begin to see patterns in documentation, recognize key elements in provider notes, and become more confident in applying the rules of coding accurately. You’ll also develop the communication skills needed to offer constructive feedback to providers, which is an essential part of the auditing role.
Most importantly, remember that no one becomes an expert overnight. Keep learning, stay curious, and don’t be afraid to ask questions, whether it’s about a confusing note, a new guideline, or how to interpret a code. The more you engage with the material and apply what you learn, the more successful you’ll become as a biller and auditor.
Alexis Combs, CPC
Alexis Combs is a Certified Medical Coder with a passion for accuracy, compliance, and helping healthcare organizations thrive. With over four years of experience in medical coding and reimbursement, she’s developed a true appreciation for how proper documentation and precise coding keep the business of medicine moving. Alexis loves taking complex information and turning it into clear, compliant codes that reflect quality care and support providers’ success.
She’s had the honor and pleasure of working with dozens of organizations in healthcare marketing, helping them share their message, build stronger connections, and bring clarity to the ever-changing world of healthcare. Alexis enjoys blending her love for coding with her creative side, finding new ways to make education, compliance, and communication both effective and engaging.
