What E/M Coding Is

Understand Evaluation and Management visit codes, how they are selected, and what Suki recommends from a completed clinical note

Evaluation and Management (E/M) codes represent the level of evaluation and management provided during a visit and are used in the billing process. For office and outpatient visits, these are the visit codes clinicians and coding teams assign once the clinical documentation is complete.

The clinical note records what happened during the visit, including problems addressed, history, exam findings, and the plan. The E/M code summarizes that visit for billing: what kind of visit it was, whether the patient is new or established, and how involved the visit was.

Clinical Note

The completed documentation for the visit, including problems addressed, history, exam findings, and the plan.

E/M Visit Code

A short billing code that describes the kind of visit and how involved it was, such as 99214.

An E/M code is not a procedure code. It does not describe a specific service such as an X-ray or lesion removal. It describes the visit itself.

A common example is 99214, an established-patient office visit at a moderate level. Your coding team may select a different code for the same chart. Suki recommends a code for review; your application remains responsible for acceptance and submission.

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How E/M codes are selected

After the note is complete, clinicians or coding teams review the documentation and available E/M code details, then select the code that fits. Selection usually follows one of these paths:

Problem Complexity

How involved the problems were, based on problems addressed, information reviewed, and risk of the treatment plan.

Documented Time

The total time spent on the patient that day, when your practice bills by time.

Preventive or Wellness

A preventive or wellness visit, using the patient’s date of birth, the date of the visit, and the visit type.

Suki follows the same idea as the example above and the way review team select the code. You provide the completed note and any available visit details. Suki returns a recommended E/M code with supporting rationale that reflects the path it used.

You provide the following details to Suki so it can recommend the E/M code when you submit the note:

Detail you provide	Why it matters and how Suki uses it
Note sections	The clinical note Suki uses to recommend the E/M code from. Each section can contain a LOINC code and the section text, which you send when you submit the note yourself and which Suki writes from the note.
Patient type	Specify whether the patient is new or established, as this affects the applicable visit codes.
Date of birth, date of service, and visit type	Include these for a preventive or wellness visit, and the visit type must be one Suki supports.
Total time in minutes	Provide the total time when billing by time.
Diagnoses	Optionally provide diagnoses already recorded for the encounter. Send ICD-10 or IMO, which Suki uses with the note when it recommends the E/M code, and you can include SNOMED even though Suki does not use it for that code. Do not send HCC on this request, because validation fails, and an HCC in Ambient structured data is separate from the E/M recommendation.

Each recommended code is driven by one selection path. If the rationale is based on problem complexity, you will not also receive a time-based rationale for that same code.

Field names and payload examples live in the how-to guides. Here you get what the code means and what Suki returns.

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What to present for review in your application’s UI

The clinician who completed the note usually reviews the recommendation first while some applications send it to a coding team for review instead. Treat it as a starting point the reviewer can check, and keep it out of billing until someone in your application accepts the code or selects a different one.

When you present the recommendation for review in your application, we recommend showing these details in the review screen:

1. E/M Code

   Put the recommended code where the reviewer sees it first, such as 99214.

2. Patient Type and Level

   Beside the code, show whether the patient is new or established and what level the visit is.

3. Reason

   Show why Suki recommended that code. For medical decision making, show the rationale, and when those details are present, also show the problems, the data reviewed, and the risk. For a time-based code or a wellness code, show the evidence for that path.

4. Modifiers and Add-Ons

   Show modifiers and add-on codes only when Suki includes them, and leave both off the screen when they are empty.

After the reviewer accepts the code or selects a different one, your application sends that code into the billing workflow you already use.

Suki recommends codes but does not submit claims, send codes to payers, or update your EHR or billing system. Your application remains responsible for reviewing the recommendations and handling the billing process.

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Next steps

E/M Coding overview - How E/M Coding supports revenue cycle workflows.

Choose Ambient or standalone - Which integration path fits your workflow.

Get the generated E/M codes - Read the code and supporting rationale from the response.