Coding Gynecologic Office Visits: AUB is Not Always “Simple”

by Nichole Mahnert, MD · July 20, 2026

Coding Gynecologic Office Visits: AUB is not always “simple”

Since the 2021 office/outpatient Evaluation and Management (E/M) changes, visit level is based on 1) Medical decision making (MDM) or 2) Total time.

For MDM, you need 2 of 3 elements: Problems, Data, and Risk to meet the level of complexity – Straightforward, Low, Moderate, High.

Problems: Number and complexity of Problems addressed

Data: Amount and/or complexity of data to be reviewed and analyzed

Risk: Morbidity/mortality factors and risk of complications associated with patient management

Example 1: New Patient with Abnormal Uterine Bleeding

A 46-year-old new patient presents with heavy, irregular bleeding. You review outside PCP and ED records/labs, order a transvaginal ultrasound, and discuss differential diagnosis including PALM-COEIN focusing primarily on structural or ovulatory causes. No medication is prescribed yet.

This may support moderate MDM with proper documentation:

Problems: AUB in a perimenopausal patient may be an undiagnosed new problem with uncertain prognosis.

Data: Moderate data may be met by three Category 1 elements, such as: review of PCP note, review of ED note/labs, and ordering pelvic ultrasound.

Risk: May be low if no prescription or procedure decision is discussed. If you reviewed hormone options including risks of using or not using the medication and patient declines prescription, this may still be considered moderate risk.

Because problems + data are moderate, the visit supports 99204. Alternatively, code by time if total physician/QHP time is 45–59 minutes on the date of service. You might consider timing how long you spend on each chart encounter, it may surprise you. Generally coding with E/M is more efficient. Remember that if you have a trainee, their time does not contribute to total time.

Documentation tip: You can only code for what is documented. If you specify what outside records were reviewed, what test was ordered, why the diagnosis/prognosis is uncertain, and the details of medical or surgical counseling you can code a level 4. Without these items documented this would be a level 3.

Example 2: Established Patient Return Visit

An established patient returns for persistent AUB. Ultrasound shows a thickened endometrium and small fibroids. You review the imaging, counsel on differential and management, discuss the option of changing medication to another oral medication or an IUD, and plan endometrial biopsy.

This often supports 99214:

Problems: Chronic illness with exacerbation/progression or undiagnosed problem with uncertain prognosis.

Data: Likely limited in this scenario

Risk: Prescription drug management discussion is generally moderate risk.

If an endometrial biopsy is performed the same day and a significant, separately identifiable E/M service is provided, consider 99214-25 plus the procedure code, as supported by documentation.

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