What is the highest E/M level that can be billed for the primary care exception?

The primary care exception allows certain providers to bill for evaluation and management (E/M) services with a focus on comprehensive care to patients, enabling higher levels of care to be recognized in specific situations. Among the levels of service defined in the E/M coding categories, the third level, or Level III, is the highest that can be billed under this exception.

This limitation is based on the understanding that while primary care providers often deliver high-quality, extensive care to their patients, the intricacies of more complex or specialized care—reflected in higher billing levels—are not typically met in a primary care setting. A Level III visit adequately reflects the nature of care usually provided, offering a suitable compensation structure that accounts for the time, effort, and expertise involved in these encounters.

The distinction in billing levels ensures that primary care practices are able to provide effective management and coordination of patient care without stepping into the complexities and billing opportunities that higher-level services entail, which are often associated with specialists. Therefore, Level III represents the highest appropriate billing level for services categorized under the primary care exception.