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E/M Coding and Billing Res...
Office/Outpatient E/M Visi...

Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

Download the Office E/M Coding Changes Guide (PDF)

List With CPT Codes For New Patient Office Visits | Short & Long Descriptions and Lay-Terms

4 CPT codes describe the procedures for a new patient office visit . These codes are used to record the level of complexity of the evaluation, management, and medical decision-making during the visit. You can find a complete list of office visits for both established patients and new patients here.

1. CPT Code 99202

Lay-term: CPT code 99202 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and straightforward medical decision making. The total time spent on the encounter must be 15 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.

Short description: New patient office visit, straightforward medical decision making, 15 minutes.

1.2. CPT Code 99203

Lay-term: CPT code 99203 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a low level of medical decision making. The total time spent on the encounter must be 30 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.

Short description: New patient office visit, low level medical decision making, 30 minutes.

1.3. CPT Code 99204

Lay-term: CPT code 99204 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a moderate level of medical decision making. The total time spent on the encounter must be 45 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.

Short description: New patient office visit, moderate level medical decision making, 45 minutes.

1.4. CPT Code 99205

Lay-term: CPT code 99205 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a high level of medical decision making. The total time spent on the encounter must be 60 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.

Short description: New patient office visit, high level medical decision making, 60 minutes.

How To Use CPT Code 28750

CPT 28750 is a code for arthrodesis of the great toe’s metatarsophalangeal joint, a surgical procedure to treat end-stage osteoarthritis. This article will cover the description, procedure, qualifying circumstances, billing guidelines, documentation requirements, historical information, similar codes, and examples of CPT 28750. 1. What is CPT 28750? CPT 28750 is a medical code used to…

How To Use CPT Code 92100

CPT 92100 describes the process of serial tonometry, which involves multiple measurements of intraocular pressure over an extended time period. This article will provide an overview of CPT code 92100, including its official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes. 1. What is CPT Code 92100? CPT…

CPT Codes For Excision Procedures On The Tongue And Floor Of Mouth

Below is a list summarizing the CPT codes for excision procedures on the tongue and floor of the mouth. CPT Code 41100 CPT 41100 describes a biopsy of the anterior two-thirds of the tongue. CPT Code 41105 CPT 41105 describes a biopsy of the posterior one-third of the tongue. CPT Code 41108 CPT 41108 describes…

How To Use CPT Code 99304

CPT 99304 refers to the initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. This article will cover topics such as the description, procedure, qualifying circumstances, when to use the code, documentation requirements,…

(2023) CPT 62323 | Description, Guidelines, Reimbursement & Billing Examples

CPT 62323 can be used when the Physician administers diagnostic or therapeutic substance or injection such as an anesthetic, steroid, antispasmodic, opioid, or other solution and not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar, or sacral (caudal); with imaging guidance such as fluoroscopy or CT. Description Of CPT 62323…

Key Takeaways:

Understanding E/M codes and guidelines is crucial for accurate billing.
There are different levels of E/M codes based on medical decision-making or time involved.
Recent changes to E/M coding include the elimination of history and physical exam elements.
The definition of time for E/M services has been expanded.
Proper documentation and coding help maximize payment and reduce audit-related stress.

Overview of Office Visit CPT Code Changes

The CPT Editorial Panel made significant revisions to the documentation and coding guidelines for office visit E/M services in 2021, with further changes introduced in 2023. These updates aim to simplify documentation requirements, reduce administrative burden, and ensure accurate coding for evaluation and management services.

One of the key changes introduced is the addition of add-on code G2211. This code accounts for the resource costs associated with visit complexity inherent to primary care and other longitudinal care settings. The inclusion of this add-on code reflects a more comprehensive understanding of the unique challenges and workload associated with these types of visits.

Additionally, the revisions eliminate the requirement for history and physical exam elements to be considered in E/M code level selection. This change allows healthcare providers to focus more on medical decision-making (MDM) and limits the need for extensive documentation of these elements in the medical record.

The MDM table has also been revised to better reflect the cognitive work required for evaluation and management services. This ensures that the complexity of the MDM is accurately captured in the coding process and supports appropriate reimbursement for the level of care provided.

Furthermore, the definition of time for many E/M services has been expanded. The expanded definition of time includes both face-to-face and non-face-to-face components of care on the day of the encounter. This change recognizes the comprehensive nature of care provided and allows for a more accurate reflection of the time spent in the management of the patient.

Using Total Time for Office Visit CPT Code Selection

When it comes to selecting the appropriate office visit CPT code, total time can be a valuable factor to consider. Total time refers to the sum of all the physician’s or qualified health professional’s (QHP) time spent in caring for the patient, both face-to-face and non-face-to-face, on the day of the encounter. This expanded definition of time allows for a more comprehensive evaluation and management of the patient’s needs.

Total time can be utilized in selecting the level of service for various evaluation and management services, including office visits, inpatient and observation care, consultations, nursing facility services, home and residence services, and prolonged services. It provides a broader perspective on the physician’s involvement in the patient’s care, taking into account all aspects of their interaction.

However, it’s important to note that for emergency department visits, the level of service is still determined primarily by medical decision-making (MDM), rather than total time. This distinction recognizes the critical nature of emergency care and the need for prompt assessment and action.

Accurate documentation of the total time spent is key to ensuring proper code selection and appropriate reimbursement. The total time should be well-documented in the patient’s medical record, including both the face-to-face and non-face-to-face components of the encounter. This documentation serves as a crucial reference point for billing and auditing purposes.

To summarize, total time offers a comprehensive perspective on the physician’s engagement with the patient, encompassing both face-to-face and non-face-to-face interactions. It allows for a more accurate selection of office visit CPT codes and ensures the appropriate level of reimbursement for the provided services. Proper documentation of total time is essential to support the medical necessity of the encounter and maintain compliance with coding and billing guidelines.

Documentation Requirements for Total Time Calculation

When determining the total time for selecting office visit CPT codes, it is essential to adhere to specific documentation requirements. By accurately documenting the time spent on various activities during the encounter, healthcare providers can ensure proper code selection and optimize reimbursement.

To calculate the total time for office visit code selection, the following activities should be included:

Reviewing external notes/tests
Performing an examination
Counseling and educating the patient
Documenting in the medical record

These activities reflect the time personally spent by the physician or qualified health professional (QHP) on the date of the encounter. However, there are also activities that should be excluded when calculating total time:

Time spent on activities typically performed by ancillary staff
Time related to separately reportable activities

It is crucial to specifically document the total time spent on each activity during the date of the encounter, rather than providing generic time ranges. This detailed documentation ensures transparency and accuracy in code selection and reimbursement.

In addition to capturing face-to-face time, it is important to record non-face-to-face time as well. Non-face-to-face time includes tasks performed outside of direct interaction with the patient, such as reviewing test results or consulting with other healthcare professionals.

Example of Total Time Calculation:

Let’s consider an example where a family physician spends the following time on a patient encounter:

45 minutes performing an examination and counseling
15 minutes reviewing external notes/tests
10 minutes documenting in the medical record
5 minutes discussing with an ancillary staff

In this case, the total time would be calculated as follows:

By accurately documenting the specific total time spent on each activity and excluding ancillary staff time, healthcare providers can ensure proper code selection and reimbursement. This meticulous documentation of total time in the medical record provides a comprehensive overview of the services rendered and supports accurate billing.

Split or Shared Visit Documentation Guidelines

A split or shared visit occurs when a physician and other qualified health professional (QHP) provide care to a patient together during a single Evaluation and Management (E/M) service. In such cases, the time personally spent by the physician and QHP on the date of the encounter should be summed to define the total time.

However, only distinct time should be counted. This means that overlapping time during jointly meeting with or discussing the patient should not be double-counted. The distinct time should represent the unique contribution of each provider involved in the split or shared visit.

It is important to note that time spent on activities performed by ancillary staff should not be included in the total time calculations. The total time should only reflect the face-to-face time and distinct time spent by the physician and other QHP directly involved in providing the medically necessary services.

Documentation should support the medical necessity of both services reported in a split or shared visit scenario. This includes clearly documenting the need for both physicians or QHPs to be involved and the services each provider contributed to the patient’s care.

Applying Total Time to Specific E/M Services

Total time is a valuable tool for selecting the appropriate level of service for a variety of Evaluation and Management (E/M) services. This method can be applied to different specific E/M services, ensuring that the level of care is clinically appropriate and adequately reimbursed. By considering the total time spent during the encounter, healthcare providers can accurately assign the appropriate office visit CPT code.

The application of total time is not limited to office visit services. It can also be used for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services. This flexibility allows for a comprehensive approach to E/M coding, regardless of the specific type of service provided.

When selecting the visit level based on total time, it is important to ensure that the encounter is counseling-dominated. While total time can be used as the sole determinant for selecting the visit level, counseling should still play a significant role in the encounter. This ensures that the level of service reflects the complexity and intensity of the counseling provided during the visit.

It is crucial to emphasize that total time should be clinically appropriate and supported by documentation in the medical record. This documentation should clearly demonstrate the medical necessity of the services provided and the time spent on the date of the encounter.

Applying Total Time to E/M Services: An Example

To illustrate the application of total time to specific E/M services, let’s consider an example of an office visit for a counseling-dominated encounter:

In this example, the total time spent during the encounter determines the appropriate level of visit code. For a total time of 25 minutes, a level 3 visit (CPT code 99213) is selected. If the total time is 40 minutes, a level 4 visit (CPT code 99214) would be appropriate. Finally, a total time of 60 minutes would result in a level 5 visit (CPT code 99215).

By applying total time to specific E/M services, healthcare providers can ensure accurate coding and appropriate reimbursement for the care provided. This method promotes comprehensive and patient-centered care while maintaining compliance with coding guidelines. Understanding the nuances of applying total time is essential for optimizing billing practices and promoting quality healthcare delivery.

Caveats and Considerations for Time-based E/M Coding

When utilizing time as the basis for selecting E/M codes, there are important caveats and considerations to keep in mind. Time-based coding should only be used in situations where counseling dominates the encounter, and it should not include time spent on separately reportable services. Documentation should clearly indicate that the services provided were not duplicative and were necessary for the management of the patient. Additionally, it is crucial to note that the professional component of diagnostic tests/studies and activities performed on a separate date should not be included in the total time calculation.

Considerations for Time-based E/M Coding

Use time-based coding only when counseling dominates the encounter.
Exclude time spent on separately reportable services.
Ensure documentation supports the necessity of the provided services.
Do not include the professional component of diagnostic tests/studies.

Implications of Time-based E/M Coding

When selecting E/M codes based on time, it is important to adhere to the specified guidelines and considerations. Failing to do so can lead to inaccurate coding, reimbursement issues, and potential compliance concerns. By understanding the requirements and accurately documenting the relevant information, healthcare providers can ensure proper medical billing and maintain compliance with coding and documentation guidelines.

Documentation Requirements for Time-based E/M Coding

Updates and Changes to CPT E/M Guidelines

The CPT Editorial Panel has recently implemented updates and changes to the Evaluation and Management (E/M) guidelines, specifically focusing on medical decision making (MDM), history, and exam. These updates aim to enhance the accuracy and specificity of E/M coding and documentation.

One significant change in the new guidelines is the emphasis on a medically appropriate history or exam, rather than relying solely on the number or complexity of problems addressed. This shift highlights the importance of gathering comprehensive patient information to guide medical decision making.

The MDM levels have also been revised to align with those used for office visits. This alignment ensures consistency across different types of E/M services and facilitates accurate code selection for medical billing and reimbursement.

By updating and refining the guidelines, the CPT Editorial Panel aims to streamline the coding and documentation process, making it easier for healthcare providers to accurately capture the complexity of patient encounters and facilitate proper reimbursement.

Changes in CPT E/M Guidelines

The updates in the CPT E/M guidelines bring about significant changes in capturing the complexity of patient encounters. Healthcare providers should familiarize themselves with these updates to ensure compliance with the revised guidelines, thereby facilitating accurate coding, billing, and reimbursement.

Guidelines for MDM Selection in E/M Services

In the process of selecting the appropriate E/M codes for evaluation and management (E/M) services, medical decision making (MDM) plays a crucial role. MDM encompasses several factors that need to be considered, including the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

It is important to note that the final diagnosis alone does not determine the complexity of MDM. Rather, the complexity is determined by the impact of the condition on the management of the patient. The more complex the problems, comorbidities, and data analysis, as well as the higher the risk of complications, morbidity, or mortality, the more intricate the MDM.

In accurately reflecting the level of complexity in the documentation and coding of E/M services, healthcare providers ensure proper reimbursement and compliance with coding guidelines. By carefully evaluating the factors that contribute to MDM, providers can effectively demonstrate the complexity of the problems addressed and the resources required to manage them.

Here is a breakdown of the key considerations for MDM selection in E/M services:

Number and complexity of problems addressed
Comorbidities
Amount and complexity of data reviewed and analyzed
Risk of complications, morbidity, or mortality
Final diagnosis and its impact on management
Complexity of problems and their management

Accurately documenting and coding the appropriate level of MDM is essential for ensuring proper reimbursement and comprehensive representation of the complexity of the patient’s condition. It is crucial to pay attention to the specifics of each patient’s case and make informed decisions based on thorough evaluation and analysis.

Impact of Office Visit CPT Code Changes on Medical Billing

The changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. Healthcare providers must adapt to these changes and understand the documentation requirements and accurate coding necessary to ensure proper reimbursement and reduce the risk of audits.

Accurate coding is crucial in accurately reflecting the level of service provided during the office visit. It ensures that healthcare providers receive accurate reimbursement for their services and helps to reduce the burden of potential audits. Proper documentation and coding also contribute to compliance with coding and documentation requirements, mitigating the risk of financial loss and noncompliance.

It is essential for healthcare providers to familiarize themselves with the new guidelines and understand how to properly document the relevant information. This includes accurately capturing the level of service provided, the complexity of problems addressed, and the time spent on the date of the encounter. By adhering to these documentation requirements, healthcare providers can ensure accurate coding and reimbursement, reducing the risk of claims denials or audits.

Proper documentation not only helps in accurate coding and reimbursement but also simplifies auditing processes, ensuring compliance with coding and documentation requirements. Auditing plays a vital role in the healthcare system, and having the appropriate documentation in place can streamline the auditing process and provide evidence of accurate and compliant billing practices.

Compliance with coding and documentation requirements is essential to avoid potential financial loss and maintain a good standing within the healthcare industry. By accurately documenting and coding office visit services, healthcare providers can demonstrate their commitment to compliance and ensure that they are providing high-quality care to their patients.

In conclusion, the changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. It is crucial for healthcare providers to understand the documentation requirements, accurately code the services provided, and ensure compliance with coding and documentation guidelines. By doing so, healthcare providers can streamline the billing process, reduce the risk of audits, and ensure accurate reimbursement for their services.

Resources for Understanding Office Visit CPT Code Guidelines

When it comes to understanding the guidelines for office visit CPT codes and navigating the changes in E/M coding, healthcare providers can rely on valuable resources provided by reputable organizations such as the American Medical Association (AMA) and the Medicare Learning Network (MLN). These resources offer comprehensive guidance and tools that can help healthcare providers stay up to date and ensure accurate reimbursement.

The CPT Evaluation and Management Services Guidelines, developed by the AMA, provide detailed information on office visit CPT codes, E/M coding principles, and documentation requirements. This resource serves as a comprehensive guide to help healthcare providers understand the intricacies of office visit coding and ensure compliance with the latest guidelines.

The Medicare Learning Network, an educational resource developed by the Centers for Medicare & Medicaid Services (CMS), offers webinars, articles, and other educational materials specifically designed to assist healthcare providers in understanding and implementing the changes in E/M coding. These resources provide practical insights and clarification on the documentation requirements and coding changes specific to office visit CPT codes.

Furthermore, the Medicare Physician Fee Schedule Lookup Tool, available on the CMS website, enables healthcare providers to access reimbursement information for specific office visit CPT codes. This tool allows providers to accurately determine the appropriate reimbursement for their services and ensure proper billing practices.

By leveraging these resources, healthcare providers can enhance their understanding of office visit CPT code guidelines, navigate the complexities of E/M coding, and ensure accurate reimbursement for their services. Staying informed and utilizing these valuable resources is imperative for maintaining compliance and optimizing coding practices.

Understanding the guidelines for office visit CPT codes is essential for accurate medical billing and insurance reimbursement. The recent changes in E/M coding guidelines, particularly regarding time-based code selection and medical decision making, necessitate proper documentation and accurate coding. By comprehensively understanding these guidelines, healthcare providers can maximize their payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

Accurate medical billing is crucial for healthcare practices to receive fair reimbursement from insurance companies. By following the comprehensive guide provided by the American Medical Association (AMA) and the Medicare Learning Network (MLN), healthcare providers can confidently navigate the complexities of office visit CPT codes. This comprehensive guide provides detailed information on selecting the appropriate codes based on medical decision making, time-based code selection, and documentation requirements.

Properly documenting the relevant information and coding accurately not only ensures accurate reimbursement but also reduces the risk of audits and increases compliance. By adhering to the guidelines and best practices outlined in the comprehensive guide, healthcare providers can maintain accurate and compliant medical billing practices, ultimately benefiting both their practice and their patients.

In conclusion, understanding the guidelines for office visit CPT codes is crucial for accurate medical billing and insurance reimbursement. By following the comprehensive guide provided by industry resources such as the AMA and MLN, healthcare providers can navigate the changes in E/M coding and ensure compliance with coding and documentation requirements. This comprehensive understanding of the guidelines allows healthcare providers to optimize payment, minimize audit-related stress, and maintain accurate and compliant medical billing practices.

What are office visit CPT codes?

Office visit CPT codes are evaluation and management (E/M) codes used for billing purposes in family medicine practices and other healthcare settings.

What are the changes to the office visit CPT code guidelines?

The office visit CPT code guidelines have been revised to eliminate the history and physical exam elements, introduce an add-on code for visit complexity, revise the medical decision-making table, and expand the definition of time for E/M services.

How can total time be used for office visit CPT code selection?

Total time, which includes both face-to-face and non-face-to-face interactions, can be used to select the level of service for office visit codes and other E/M services.

What should be included in the calculation of total time for office visit code selection?

Activities such as examining the patient, counseling and educating the patient, reviewing external notes/tests, and documenting in the medical record should be included in the calculation of total time. Ancillary staff time and time related to separately reportable activities should be excluded.

How should total time be documented for office visit code selection?

It is important to document the specific total time spent on activities on the date of the encounter in the patient’s medical record, rather than providing generic time ranges.

What are the documentation guidelines for split or shared visits?

In a split or shared visit scenario, the time personally spent by the physician and other qualified health professional (QHP) should be summed to define total time. Distinct time should be counted, and time spent on activities performed by ancillary staff should not be included.

Can total time be used for other E/M services besides office visits?

Yes, total time can be used to select the level of service for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services.

What are the caveats and considerations for time-based E/M coding?

Time-based coding should only be used when counseling dominates the encounter, and it should not include time spent on separately reportable services. It is important to ensure that the services provided were necessary for the management of the patient.

What updates have been made to the CPT E/M guidelines?

The CPT E/M guidelines have been updated to emphasize the need for a medically appropriate history or exam and to revise the levels of medical decision making to align with office visit levels.

How is medical decision making (MDM) determined in E/M services?

MDM is determined by considering the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

What is the impact of the office visit CPT code changes on medical billing?

The changes in office visit CPT code guidelines have a significant impact on medical billing, requiring proper documentation and accurate coding to ensure accurate reimbursement and reduce the risk of audits.

Where can healthcare providers find resources to understand the office visit CPT code guidelines?

Healthcare providers can refer to resources such as the CPT Evaluation and Management Services Guidelines from the American Medical Association and the Medicare Learning Network for guidance on understanding and implementing the office visit CPT code guidelines.

What is the importance of understanding office visit CPT code guidelines?

Understanding office visit CPT code guidelines is crucial for accurate medical billing, insurance reimbursement, and compliance with coding and documentation requirements.

What is the overall purpose of the comprehensive guide on office visit CPT code guidelines?

The comprehensive guide on office visit CPT code guidelines provides healthcare providers with a thorough understanding of the guidelines, enabling them to maximize payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

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99201-99215: Office/Outpatient E/M Coding in 2020

Note: The article below was posted in 2020 and applies to coding for 2020 dates of service. For information about coding office and other outpatient E/M services in 2021, Please see 99202-99215: Office/Outpatient E/M Coding in 2021 .

Evaluation and management (E/M) coding is a high-volume area of CPT ® medical coding, meaning that healthcare providers report E/M codes often on medical claims. The codes apply to services that a wide range of primary care and specialty providers perform regularly. Some of the most commonly reported E/M codes are 99201–99215, which represent office or other outpatient visits.

In 2020, the E/M codes for office and outpatient visits include patient history, clinical examination, and medical decision-making as the key components for determining the correct code level, and that's the version of the codes that this article focuses on. Anyone interested in E/M coding should be aware that both the American Medical Association (AMA), which maintains the CPT ® code set , and the Centers for Medicare & Medicaid Services (CMS) have announced plans for major changes to office/outpatient E/M coding and documentation requirements in 2021 . Once those changes are implemented, much of the information below, particularly the material related to key components, will no longer apply to office/outpatient E/M coding.

When to Use New and Established Patient E/M Codes

An important concept for proper use of office/outpatient E/M codes 99201–99215 is that CPT ® divides the codes based on whether the encounter is for a new patient or an established patient.

Codes 99201–99205 apply to new patient visits. The descriptors for all 5 of the codes (99201, 99202, 99203, 99204, and 99205) begin with the same language, including a reference to a new patient: Office or other outpatient visit for the evaluation and management of a new patient … .

Similarly, the descriptors for the established-patient codes (99211, 99212, 99213, 99214, and 99215) share a common beginning that refers to an established patient: Office or other outpatient visit for the evaluation and management of an established patient … .

To determine whether you should choose between new patient codes 99201-99205 or established patient codes 99211-99215, you need to know CPT ® ’s definition of new and established patients for E/M purposes . In short, a patient is established if the same provider, or any provider of the same specialty and subspecialty who belongs to the same group practice, has seen that patient for a face-to-face service within the past 36 months. Patients who don’t meet that definition are new patients.

For instance, consider this example of an established patient seeing a physician in an office for an E/M service. A patient saw a neurosurgeon for a face-to-face visit 26 months ago. The patient presents to the office now to see the same neurosurgeon for symptoms of lower back pain. Because the neurosurgeon provided a face-to-face service to the patient within the past 3 years, the neurosurgeon should consider this patient to be established when reporting the current E/M for lower back pain.

One final factor to consider regarding new and established patient definitions is that third-party payers may have their own rules. As an example, Medicare refers to providers of the same specialty in its definition of new and established patients, but there's no reference to subspecialty. This is in line with Medicare’s rule that “physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician,” which you can find in Medicare Claims Processing Manual , Chapter 12 , Section 30.6.5.

New Patient E/M: 3 of 3 Key Components

To report an office or other outpatient visit for a new patient, you'll choose from E/M codes 99201-99205. As this article mentioned previously, office/outpatient visits include history, clinical examination, and medical decision-making (MDM) as the 3 key components for code selection. To determine which E/M code from 99201-99205 is appropriate for a specific encounter, you must check the stated levels for the key components in each descriptor. A new patient visit must meet the levels listed for all 3 key components to qualify for a given code level.

Reviewing the sample E/M code descriptor below will help make those instructions about key components clearer. The areas specific to the key components are shown in bold text for emphasis.

99203 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

A detailed history;

A detailed examination;

Medical decision making of low complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

As you can see above, the code descriptor specifies the levels of history, exam, and MDM required for the particular code. The key component levels necessary for each code in the range vary. Table 1 shows the key component requirements for each code from 99201-99205.

Table 1: Key Components for New Patient Office/Outpatient E/M Visits

(Visit must meet or exceed all 3 key components in a row to qualify for the code)

Because you must meet (or exceed) the requirements for all 3 key components, the lowest level key component for the visit will determine which new patient E/M code is appropriate. As an example, suppose the physician sees a new patient for an office visit. The physician documents a comprehensive history and exam, and MDM of low complexity. The history and exam levels in the example visit match the requirements listed for 99204 and 99205, but the lowest level key component (in this case, the low complexity MDM) determines the correct E/M code. As a result, you should select 99203 for this visit because the code meets the MDM requirement and exceeds the history and exam requirements.

Established Patient E/M: 2 of 3 Key Components

You have just seen that a new patient E/M visit in the office/outpatient setting must meet the levels for all 3 key components listed in a descriptor to qualify for that code. In contrast, the office/outpatient E/M codes for an established patient, 99212-99215, require a visit to meet only 2 of the 3 key components listed to support the service level. Code 99211 does not reference the 3 key components in its descriptor, and you will learn more about that code later in this article.

Table 2 shows the key component requirements for the different established patient office/outpatient E/M code levels.

Table 2: Key Components for Established Patient Office/Outpatient E/M Visits

(Visit must meet at least 2 of 3 key components in a row to qualify for the code)

To understand the role of key components for an established patient visit in the outpatient setting, consider this example: A provider documents a problem focused history, expanded problem focused exam, and low complexity MDM. In this case, your best choice is level-3 code 99213 (bold added for emphasis):

99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

An expanded problem focused history;

An expanded problem-focused examination;

Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family .

Although the problem-focused history meets the requirements listed for 99212, both the exam and MDM levels support 99213. Because you need to meet the requirements for only 2 of 3 key components when selecting an established outpatient E/M service, 99213 is correct.

Confirm Clinical Indications for 99211

Code 99211 differs from the other office visit codes in that it doesn't require the 3 key components. Additionally, the code descriptor specifies that the visit may not require the presence of a physician or other qualified healthcare professional:

99211 - Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

You may hear 99211 unofficially referred to as a nurse visit code because a nurse can perform the service without the billing provider present in the room, and face-to-face visits with physicians and nonphysician practitioners tend to meet the standards for higher level E/M codes. But 99211 can apply to brief but medically necessary visits with a physician or a nonphysician practitioner, such as a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife.

An example of appropriate use of 99211 may involve blood pressure monitoring for a hypertensive patient under a physician’s plan of care, as long as there is established medical necessity for the blood pressure check.

For instance, suppose a physician examines a 65-year-old female patient and finds that her blood pressure is high. He decides to put her on medication to treat the problem. He notes in the chart the patient should return in 2 weeks to see the nurse for a follow-up visit that includes a blood pressure check, an evaluation of how the new blood pressure medicine is working, and a review of any symptoms the patient has had since starting the new medication. In this case, documentation may support reporting 99211 for the low-level visit to the nurse.

As the example emphasizes, the documentation should show clinical indications prompted the intervention to support using 99211. If a stable patient comes in to have her blood pressure checked by the nurse just because the patient wants to know the reading, the visit probably won’t merit use of 99211.

Coding E/M Based on Time

Selecting an office/outpatient E/M code based on the key components is not the only option available. CPT ® and Medicare guidelines also allow you to select from these E/M codes based on time.

This approach to E/M coding applies only when counseling and/or coordination of care dominate the encounter. The medical record must include the extent of counseling and/or coordination of care and make it clear that more than 50% of the encounter was spent on those services.

To make your code choice, you need to know the intraservice time for the visit, which means face-to-face time for office and other outpatient visits. You then need to compare that time to the typical times listed in the E/M code descriptors. For instance, the descriptor for 99213 states, “Typically, 15 minutes are spent face-to-face with the patient and/or family.” Payer requirements may vary for whether you must meet the time listed or are allowed to round up from the midway point to determine the final code choice.

Reporting Multiple Same-Day E/Ms

In some cases, a provider may perform more than 1 office or outpatient E/M service for a patient on the same day. New patient E/M codes 99201-99205 and established patient E/M codes 99211-99215 don’t state “per day” in their descriptors, but payer rules may prevent you from reporting more than 1 E/M code for a single patient on the same date of service.

For instance, Medicare will “not pay 2 E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day,” according to Medicare Claims Processing Manual , Chapter 12, Section 30.6.7.B.

There's an exception to Medicare’s rule about reporting multiple office and outpatient E/M services on the same date, though. If the provider documents that the visits were for unrelated problems and the services couldn't be provided during the same encounter, then Medicare allows you to report separate E/M codes for the same date. The example the Medicare manual provides is a patient presenting for blood pressure medication evaluation and then returning 5 hours later for evaluation of leg pain following an accident.

To support reporting the services separately, experts advise maintaining distinct documentation for each service. You also will need to check payer preference for which modifier to append to the additional E/M code, such as modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service or modifier 59 Distinct procedural service .

If a provider sees the patient twice on the same day for related problems, and the payer doesn’t allow you to report those services separately, then you should combine the work performed for the 2 visits, and select a single E/ M service code that best describes the combined service. For example, if a patient comes in with elevated blood pressure, the physician may give the patient medication and then have her come back later that day to see how she is doing. In this case, because the visits are for the same complaint, you should combine the work performed for the 2 visits into a single E/M code.

E/M on Same Day as Minor or XXX Procedure

The rules related to reporting 99201-99215 on the same date as a minor procedure are confusing for many coders. You need to understand which services the payer considers separately reportable.

A minor surgical procedure is a procedure with a global period of 0 days or 10 days on the Medicare Physician Fee Schedule (MPFS). Many payers other than Medicare use this definition, as well. The global period refers to the length of time the global surgical package applies.

The basic idea of the global surgical package is that services normally performed by a provider before, during, and after a procedure are included in the surgery code instead of being reported separately. All those usual services get factored into the payment rate for the surgical code, so reporting those usual services separately would result in being paid twice for the same service. Payers scrutinize this area of coding to ensure they aren’t overpaying.

Medicare’s definitions of the 0-day and 10-day global periods, available in the MPFS relative value files , indicate that Medicare usually doesn't pay for E/M services during the global period (bold added for emphasis):

0-day global period: “Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable. ”

10-day global period: “Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10 day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during the 10-day postoperative period generally not payable .”

One reasons E/M codes during the global period are “generally not payable” is that Medicare considers a decision to perform a minor surgery made immediately before the procedure to be a routine preoperative service, according to Medicare Claims Processing Manual , Chapter 12, Section 40.2.A.4. Additionally, a certain amount of history-taking and physical exam work, as well as follow-up care, is expected for a minor procedure, so the surgical code includes payment for that work.

But the phrase “generally not payable” in the global period definitions leaves room for reporting E/M codes separately under certain circumstances. The rule is that you may report significant, separately identifiable E/M services on the same day as a minor procedure. Medicare provides the example of reporting an E/M code for a full neurological examination on the same date that you report a code for suturing a scalp wound for a patient with head trauma. But you need to ensure documentation supports reporting a distinct E/M service. “Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status,” states Medicare Claims Processing Manual , Chapter 12, Section 40.1.C.

If documentation does support reporting an E/M code on the same date as a minor procedure code, you should append modifier 25 to the E/M service code to acknowledge that special circumstances make the code reportable.

The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services , Chapter 1, states that providers also may submit a distinct E/M code with modifier 25 on the same date as a code that has an XXX global indicator. The XXX indicator means the global concept doesn't apply to the code.

Again, for you to report the E/M separately, it must be distinct from the typical pre-, intra-, and post-procedure work for the XXX-global code. That means you shouldn't report an E/M for the physician’s supervision of someone else performing the procedure or interpretation of the result of the procedure.

Note that both Medicare and CPT ® state that you don't need different diagnoses for the distinct E/M service and the procedure. But experts advise that separate diagnoses may help show that the E/M was significant and separately identifiable from the surgery. You shouldn't report separate diagnoses simply to improve your chances for payment, however. Always base your ICD-10-CM coding choices on the documentation and follow proper coding rules.

E/M Coding for Decision for Major Surgery

If a physician performs an E/M service on the same date as a major procedure or on the day before the procedure, you may report the E/M separately if the E/M resulted in the decision for surgery. You should append modifier 57 Decision for surgery to the E/M service code in this case.

A major procedure is 1 with a 90-day global period on the MPFS. The definition of a 90-day global period is “Major surgery with a 1-day preoperative period and 90-day postoperative period included in the fee schedule amount.”

As an example of proper modifier 57 use, suppose a surgeon sees a patient with extreme pain in the lower abdomen. The surgeon quickly determines that the patient’s appendix has burst and schedules immediate surgery. In this case, both the E/M service and the surgery are billable because the E/M service resulted in the decision to perform the surgery (In other words, the surgery wasn't previously planned at the time of the evaluation.). You should append modifier 57 to the E/M code.

Medical Necessity Drives E/M Code Choice

No discussion of E/M coding would be complete without mentioning medical necessity. In all cases, whether a visit involves a new or established patient, medical necessity should determine the extent of the service provided, including elements like the history, exam, and MDM. Consequently, medical necessity determines the final E/M code choice.

In the words of Medicare Claims Processing Manual , Chapter 12, Section 30.6.1, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT ® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”

Proper Use of Office/Outpatient E/M Code 99211

Evaluation and management (E/M) code 99211 is the lowest level established patient E/M code in the range for office or other outpatient visits . This level of service doesn't require the presence of a physician, which can lead practices to underestimate the importance of following reporting rules for this code. But because 99211 is an E/M code, it requires elements of evaluation and management to be performed and documented.

This quick guide offers tips on the dos and don’ts of 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

Support 99211 by Doing These 5 Things

When considering whether to assign 99211 for a service, remember these important points for proper reporting.

Do make sure there's a separate E/M service. Check for a documented evaluation of the patient along with management of the patient’s care. For example, if a nurse only refills the patient’s medications and no other E/M service takes place, you shouldn't report 99211.

Do ensure the patient is an established patient. Based on the CPT ® code description, you should report 99211 for an established patient , meaning 1 that has been seen by the rendering provider (or provider of same group and specialty/subspecialty) within the past 3 years, in any setting. You can't report 99211 for a new patient.

The established-patient rule also is important because Medicare applies the concept of incident-to services for 99211, meaning a provider previously furnished a direct, personal, professional service to initiate a course of treatment, and the 99211 service being performed is an incidental part of that care plan.

Do be certain that the supervising provider is in the office suite. Reporting 99211 to certain payers (including Medicare) requires that the supervising provider be in the office suite at the time of the appointment. The billing provider is not required, however, to be in the room or to provide face-to-face services for the patient. The supervising provider doesn’t have to be the one who created the care plan. Medicare Benefit Policy Manual, Chapter 15 , Section 60, provides more information about incident-to services.

Do bill the service under the supervising provider . All incident-to services must be billed under the provider present in the office when services were performed.

Do prove that the visit is medically necessary. Look for a documented clinical reason that supports the visit and proves it was above the scope of the other services provided that day. In other words, if you’re reporting the E/M code along with another code, make sure the E/M documentation is significant and separately identifiable from the procedure documentation. For example, a nurse may document the reason for the visit, a brief history of the patient’s illness, any exam processes such as weight or temperature, a list of the patient’s medications, and a brief assessment to support the E/M in addition to the other service performed.

3 Areas to Watch to Prevent 99211 Issues

Proper reporting of 99211 also requires you to know the top problem spots for this code so you can avoid them. Beware of these areas:

Don’t bill 99211 for services that are part of another E/M service performed on the same day. For example, if your nurse measures the patient’s blood pressure and weight prior to a visit with the physician or provides counseling after the physician has seen the patient, you should not use 99211 because those tasks are considered part of the physician’s office visit.

Don’t report 99211 for telephone calls. There must be face-to-face contact to report 99211. For example, if a nurse returns a patient’s call and gives instructions over the phone, you can’t submit 99211 for reimbursement.

Don’t underestimate the importance of documentation. Documentation is essential when requesting reimbursement for 99211 visits. The care provider must document details including the reason for the encounter, which may include educational services as well as evaluation of the patient’s condition with management directed by the physician. You also must have documentation to show that the supervising provider was in the office at the time of the visit. Documentation might be a statement indicating that the nurse was working under a physician in the office, a copy of the physician’s schedule that shows the physician was in the office at the time of the nurse visit, or a statement by the physician with signature and date.

Last reviewed on Nov 4, 2020, by the AAPC Thought Leadership Team

About the author

Thought leadership team, editorial staff / aapc.

The AAPC Thought Leadership Team is a distinguished consortium of experts, visionaries, and thought leaders committed to shaping the landscape in the industry. With a deep understanding of the profound impact our industry has on society, this council serves as a guiding force, driving the development and implementation of ethical standards in coding practices.

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E/M Rules Archive

April 28, 2024

Coding for Prolonged Services: CPT and HCPCS Codes

Common rules:

Prolonged services codes are add-on codes to E/M services.
In order to use prolonged care, the primary code must be selected based on time. This is in the CPT and HCPCS definition of prolonged services.
Prolonged services codes may only be added to the highest-level code in the category.
The full 15 minutes of prolonged services must be met. These do not follow the CPT mid-point time rule.
The work of the prolonged care may include both face-to-face and non-face-to-face time.
Prolonged care services can no longer be used on psychotherapy codes. There is no replacement code.

Where the rules vary:

There are different CPT® and HCPCS codes that describe the same prolonged care services.
In the 2024 CPT book, time ranges were removed from the office visit codes, and they now have only a single, threshold time listed. CMS has changed its manual or time thresholds for using prolonged care in response to this.
For other services (hospital, nursing facility and home and residence services), CPT® uses the times stated in the CPT® book for the primary code when calculating if a prolonged services code may be added. CMS uses the time in the CMS time file , which includes pre and post visit times on other days, to calculate if prolonged care services may be added to hospital, nursing facility and home and residence services.
CPT® includes only time spent on the date of the encounter. For hospital, nursing facility and home and residence services, CMS uses time on other dates of service.
CPT® still has non-face-to-face prolonged care in the CPT® book, codes 99358, +99359 which can be used on days that do not include a face-to-face visit. CMS has given them a status indicator of invalid and doesn’t pay for them. There is no replacement of these services for Medicare patients.
Home and residence services
Hospital services
Nursing facility for services
Table 24 from the Final rule

Implementing prolonged services codes

Coding prolonged services in the office.

CMS does not recognize consultation codes.

Note: For home and residence services and assessment of cognitive functions, see below.

Coding for prolonged services is complicated by the fact CPT ® and CMS use different codes and different time thresholds. These codes and rules have been in effect since 2021.

The AMA developed CPT ® code 99417 for 15 minutes of prolonged care, done on the same day as office/outpatient codes 99205 and 99215.
Medicare has assigned a status indicator of invalid to code 99415, and developed a HCPCS code to replace it, G2212
If using either code, only report it with codes 99205 and 99215, use only clinician time, and use it only when time is used to select the code
Use for time spent face-to-face and in non-face-to-face activities

In their 2021 Physician Fee Schedule Final Rule, CMS indicated its agreement with the new E/M definitions for codes 99202-99215 that were developed by the AMA that are in the 2021 CPT ® book. However, CMS and the AMA are not in agreement about the use of prolonged care code 99417, resulting in HCPCS code.

Using time for E/M services

A practitioner may include these activities in their time, when using time to select an E/M service:

preparing to see the patient (eg, review of tests)
obtaining and/or reviewing separately obtained history
performing a medically appropriate examination and/or evaluation
counseling and educating the patient/family/caregiver
ordering medications, tests, or procedures
referring and communicating with other health care professionals (when not separately reported)
documenting clinical information in the electronic or other health record
independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
care coordination (not separately reported)

Per CPT, use 99417 for office visits, outpatient consults, home and residence services and cognitive assessment planning.

# ✚ 99417 Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)

(Use 99417 in conjunction with 99205, 99215, 99245, 99345, 99350, 99483)

(Use 99417 in conjunction with 99483, when the total time on the date of the encounter exceeds the typical time of 99483 by 15 minutes or more.)

You can’t report the new add on code on the same day as 90833, 90936, 90838, non-face-to-face prolonged care codes 99358, 99359 or staff prolonged care codes.
The time reported must be 15 minutes, not 7.5 minutes. The entire 15 minutes must be done, in order to add on this new, prolonged services code.

CMS developed its own code G2212

G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT ® codes 99205, 99215 for office or other outpatient evaluation and management services)

(Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes)).”

Both CMS and CPT allow a prolonged service in addition to 99483, assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home. The typical time for this code is 60, making the threshold time to add a prolonged care code 75 minutes. Note that CMS allows the practitioner to include time spent three days before the date of the visit and seven days after.

Coding prolonged services in a home or residence

For CPT®, use add-on code 99417 for prolonged care. As with all of these codes, both CPT ®️ and HCPCS, the prolonged code may only be added to the highest-level code in the category and then only when time is used to select the service. The definition of 99417 is above.

G0318 ( Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99345, 99350 for home or residence evaluation and management services). (Do not report G0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417). (Do not report G0318 for any time unit less than 15 minutes) )

CMS is allowing time on days prior to and after the date of the encounter to be used for prolonged services in relation to home/residence visits.

Coding prolonged services in the hospital: CPT and HCPCS codes

99418 Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the inpatient and observation Evaluation and Management service)

(Use in 99418 conjunction with 99223, 99233, 99236, 99255, 99306, 99310) (Do not report 99418 on the same date of service as 90833, 90836, 90838, 99358, 99359) (Do not report 99418 for any time unit less than 15 minutes)

99418 may be used on the highest-level initial and subsequent inpatient and observation codes, inpatient consult, and initial and subsequent nursing facility services. It may not be reported with psychotherapy or non-face to face prolonged care codes, or discharge services 99238, 99239, 99315, 99316. It may not be used with Emergency Department codes. The full 15 minutes is required and time must have been used to select the level of service.

As expected, CMS is not recognizing the new CPT ® code 99418. For Medicare patients, there is a HCPCS code. CMS is not using the published CPT typical times for the codes, but the time in the CMS time file, developed by the RUC. For Medicare patients, the time thresholds to add G0316 are different than those in our CPT books. CMS is not using allowing practices to report G0316 when the time is 15 more minutes than the CPT ® typical time. Instead, in a break from prior policy, CMS is using the time in the CMS time file. The 2023 time file is here .

G0316 Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT ® codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). (Do not report G0316 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418). (Do not report G0316 for any time unit less than 15 minutes)

See the CMS Table 24 below. CMS is allowing time on after the date of the encounter to be used for prolonged services in relation to hospital services.

Coding prolonged services in a nursing facility

Prolonged services in a nursing facility: CPT code 99418/HCPCS code for Medicare G0317

CPT ® defines the new prolonged add-on code 99418 (above) as the code to use in a nursing facility, as well as in the hospital. And, CPT ®️ simply states to use the code when the total time of the highest-level service (selected based on time) is 15 minutes more than the time described in the CPT ®️ book. Both the base time and the prolonged time can include face-to-face care and non-direct care on the date of the visit.

G0317 ( Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99306, 99310 for nursing facility evaluation and management services). (Do not report G0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418,). (Do not report G0317 for any time unit less than 15 minutes) )

Table 24 Required Time Thresholds to Report Other E/M Prolonged Services

* Time must be used to select visit level. Prolonged service time can be reported when furnished on any date within the primary visit’s surveyed timeframe, and includes time with or without direct patient contact by the physician or NPP. Consistent with CPT’s approach, we do not assign a frequency limitation.

The source of this chart is CMS’s 2023 Final Rule. It doesn’t follow CPT typical times, or CPT prolonged services rules. It includes time for some services on the days before or after the face-to-face encounter. It adds to confusion and complexity for medical practices.

Implementation of using prolonged care HCPCS codes

It was never easy for clinicians to select prolonged services codes. When they were applicable to all levels of service, the threshold time was different for each code. Now, they are only applicable on the highest level of service, but there are two sets of codes and the time thresholds are different for each one. This makes no sense. Effectively, all prolonged services coding will need to be done by coders. Effectively, it is so byzantine that most practices will never be able to bill for them.

Add-on prolonged services HCPCS codes

Can an add-on code to be submitted without its primary code? In particular, the add-on prolonged services HCPCS codes developed by CMS.

An add-on code must be submitted with its primary code. A colleague said she was getting conflicting opinions about this. Let’s see what CPT® and CMS say.

Page xviii of the CPT® Professional Edition 2024 states, “Add-on codes are always performed in addition to the primary service or procedure and must never be reported as a standalone code.” It is easy to ignore the information in the introduction of the CPT® book but when I’m stuck, I regularly find answers there. And wish I had started looking there in the first place!

What about CMS? CMS has edits in place to ensure that an add-on code is only paid when reported with a correct primary code. Naturally, they have three levels of edits but you can read about this on the CMS website .

I think the question was prompted by the fact that for certain services provided by practitioners in a facility the add-on prolonged care codes includes time the days before or in the days after the face-to-face encounter. You can see the chart from the CMS final rule and read about it here .

I don’t know what edits individual MACs are setting up for these codes, but I recommend that you continue to submit all add-on codes on the claim with the primary code, following CPT® rules and CMS guidance.

Non-face-to-face prolonged services codes 99358, 99359

The non-face-to-face prolonged care codes are still active, billable codes. But, they may not be reported on the same date of service as 99202-99215 per CPT®. And, Medicare has given them a status code of invalid, which means they won’t pay for it. And, there is not a replacement code for this service for Medicare.

I understand from your article about prolonged services in 2021 that CMS won’t pay for prolonged code 99417 and instead developed a HCPCS code for the service. (G2212) Do you have any recommendations about how to manage this in the office?

Although in general, I believe most clinicians can code for most of the work they do (not a universally held opinion, I know) this is a case where the claims must go to a coder for review. Not only are there different codes depending on payer, the time thresholds are different. CPT® allows you to add the 15 minutes to the lower time threshold in the range, and CMS requires you to add the 15 minutes to the higher time threshold in the range.

Just a few reminders. The prolonged codes can only be used on 99205 and 99215, and only when time is used to select the office visit code. The total time must be documented. CMS’s manual does not currently require start and stop times. Look for a description of what activities are included in the time, because this is required when using time to select the office visit codes. “I spent 90 minutes caring for the patient today. It included reviewing test results, documenting in the record and arranging for follow up at pain management. It also included an extensive discussion with the patient and his sister about treatment options and recovery time, if he decides on surgery.”

Source documents

EM from 2020 Final Rule
G2212 from 2021 Final Rule

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Last revised April 8, 2024 - Betsy Nicoletti Tags: CPT updates , prolonged care

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions.

Determining whether the visit you've just finished should be coded as a level 4 could be as simple as asking yourself three questions.

KEITH W. MILLETTE, MD, FAAFP, RPH

Fam Pract Manag. 2021;28(1):27-33

Author disclosure: no relevant financial affiliations disclosed.

Performing level 4 evaluation and management (E/M) outpatient visits but coding them as level 3 visits is a costly mistake for family physicians. It can result in $30,000 or more in lost revenue in a year, depending on practice volume. Some doctors choose to report a level 3 instead of a level 4 because of fear of over-coding. 1 Some do level 4 work but their documentation is lacking and doesn't support a level 4 code. But the most common reason I've seen for under-coding level 4 visits is that the coding criteria are complex and time-consuming.

“Coding is complicated and boring,” I often hear physicians say. “I have better things to do, like take care of my patients.”

New rules for coding and documenting outpatient E/M office visits should simplify things, clear up confusion, and help you code more confidently and accurately.

The rules, which took effect Jan. 1, are the most significant changes to E/M coding since 1997 (for more details, see “ Countdown to the E/M Coding Changes ” in the September/October 2020 issue of FPM ). Coding for outpatient E/M office visits is now based solely on either the level of medical decision making (MDM) required or the total time you spend on the visit on the date of service. (See “ E/M coding changes series .”) The history and exam components are no longer used for coding purposes. (Note: these changes apply only to regular office visits and not to nursing home or hospital E/M visits.)

The 2021 E/M coding changes should help ensure you're not leaving money on the table, especially when it comes to coding level 4 visits, which is not as straightforward as coding other levels.

Doing level 4 evaluation and management (E/M) work but coding it as a level 3 office visit is a common mistake that can cost a family physician thousands of dollars each year.

Rule changes that eliminated the history and exam portions from coding requirements should make it easier to identify level 4 office visits and code them for appropriate reimbursement.

Answering three basic questions can help you identify whether you've performed a level 4 visit.

E/M CODING CHANGES SERIES

September/October 2020 — Countdown to the E/M Coding Changes

November/December 2020 — The 2021 Office Visit Coding Changes: Putting the Pieces Together

January/February 2021 — Coding Level 4 Office Visits Using the New E/M Guidelines

CODING LEVEL 4 VISITS: THE BASICS

These are the basic parameters for coding a level 4 visit based on total time or MDM under the new rules.

Total time includes all time the physician or other qualified health professional (QHP) spends on that patient on the day of the encounter. This includes time spent reviewing the patient's chart before the visit, face-to-face time during the visit, and time spent after the visit documenting the encounter. It may also include discussing the patient's care with other health professionals or family members, calling the patient later in the day, or ordering medications, studies, procedures, or referrals, as long as those actions happen before midnight on the date of service. Total time does not include time spent performing separately billed procedures or time spent by your nurse or other office staff caring for the patient.

The total time needed for a level 4 visit with an established patient (CPT code 99214) is 30–39 minutes. The total time needed for a level 4 visit with a new patient (CPT 99204) is 45–59 minutes.

Many EHRs have time calculators that will show the amount of time you have had the patient's chart open. This will help you keep track of time while you're reviewing the chart before the visit, performing the exam (if you always open the chart at the beginning of the visit and close it at the end of the encounter), and making notes after the visit. It will be less helpful for physicians who open the computer only when needed during the patient visit.

Documentation of total time is fairly straightforward: just note how much time you spent on the visit that day. You aren't required to break down how much time you spent before, during, and after the visit, though that may be helpful supportive detail in the event of an audit. You may want to include a short definition of total time so that patients who read their notes don't confuse it with face-to-face time and think, “My doctor only spent 20 minutes with me, not the 40 minutes listed here.” For example, your documentation could say, “Total time: 40 minutes. This includes time spent with the patient during the visit as well as time spent before and after the visit reviewing the chart, documenting the encounter, making phone calls, reviewing studies, etc.” In addition to preventing misunderstandings, this gives patients a better idea of all the time we spend on them outside of the actual visit. Another way to accomplish it without “note bloat” is to have a pop-up message with this information that appears in the EHR whenever patients access their notes.

Medical decision making is still made up of three elements: problems, data, and risk. But the definitions have changed somewhat (see “ CPT E/M office revisions: level of medical decision making ”). The overall level of the visit is determined by the highest levels met in at least two of those three elements. That means that for an outpatient E/M office visit to be coded as a level 4 (for new or established patients), you need at least two of the three elements to reach the “moderate” category — moderate number and complexity of problems addressed; moderate amount and/or complexity of data to be reviewed and analyzed; or moderate risk of complications and/or morbidity or mortality of patient management. An important difference between coding based on MDM versus total time is that you may count MDM that occurs outside of the date of service (e.g., data reviewed or ordered the day after the patient's visit).

To make this simpler, let's substitute “level 4” for the term “moderate” as we take a look at what qualifies in each category (problems, data, and risk).

Level 4 problems include the following:

One unstable chronic illness (for coding purposes “unstable” includes hypertension in patients whose blood pressure is not at goal or diabetes in patients whose A1C is not at goal),

Two stable chronic illnesses (e.g., controlled hypertension, diabetes, chronic kidney disease, or heart disease),

One acute illness with systemic symptoms (e.g., pyelonephritis or pneumonia),

One acute complicated injury (e.g., concussion),

One new problem with uncertain prognosis (e.g., breast lump).

Level 4 data includes the following:

One x-ray or electrocardiogram (ECG) interpreted by you,

Discussion of the patient's management or test results with an external physician (one from a different medical group or different specialty/subspecialty),

A total of three points, earned as follows: a) One point for each unique test ordered or reviewed (panels count as one point each; you cannot count labs you order and perform in-office yourself), b) One point for reviewing note(s) from each external source, and c) One point for using an independent historian.

Level 4 risk includes the following:

Prescription drug management, which includes ordering, changing, stopping, refilling, or deciding to continue a prescription medication (as long as the physician documents evaluation of the condition for which the medication is being managed),

The presence of social determinants of health (lack of money, food, or housing) that significantly limit a patient's diagnosis or treatment,

Decision about major elective surgery without identified risk factors for patient or procedure,

Decision about minor surgery with identified risk factors for patient or procedure.

IDENTIFYING LEVEL 4 VISITS IN THREE QUESTIONS

Here are three questions you can ask yourself to quickly determine whether you've just performed a level 4 visit:

Was your total time between 30 and 39 minutes for an established patient, or between 45 and 59 minutes for a new patient? If so, then you're done. Code it as a level 4 using total time.

Did you see the patient for a level 4 problem and either order/review level 4 data or manage level 4 risk? If so, then code it as a level 4 using MDM.

Did you order/review level 4 data and manage level 4 risk? If so, code it as a level 4 using MDM.

Another way to simplify coding level 4 visits is to recognize that ordering labs, x-rays, ECGs, and medications (prescription drug management) often signals level 4 work, while using independent historians, discussing care/studies with external physicians, and providing care limited by social determinants of health are not used as often to code level 4 visits. Therefore, questions 2 and 3 could be rephrased or shortened as follows:

2. Did you see the patient for a level 4 problem and either prescribe a medication, interpret an x-ray (or ECG), or order/review three tests?

3. Did you prescribe a medication and either interpret an x-ray (or ECG) or order/review three tests?

OFFICE VISIT EXAMPLES

Now let's look at three examples of level 4 office visits, documented with the usual SOAP (subjective, objective, assessment, and plan) note. See if you can identify why each is a level 4 before you get to the explanation.

Subjective: 44 yo female presents with 3 day hx of dysuria, frequency, urgency, L mid back pain, fever, chills, and nausea. Has prior hx of UTIs. No hx of pyelo. No hx of resistant infections. Able to keep food down .

Objective: T 100.2, P 96, R 18, BP 110/70. Pt looks ill but not toxic .

EYES: Fundi benign. PERRLA. TMs: Benign. PHARYNX: Benign. NECK: Benign. No cervical adenopathy. HEART: S1 and S2 w/o murmurs. LUNGS: Clear. Breathing is nonlabored. ABDOMEN: soft, nontender, moderate L CVA tenderness. EXTREMITIES no edema .

Laboratory: UA – TNTC, WBCs – 4+ bacteria .

Assessment/Plan: Pyelonephritis N12. Discussed acute pyelo, also ways to prevent bladder infections. Handout given. Push fluids. Discussed fever and pain control. Cipro 500 mg po bid x 7 days with appropriate precautions. RTC 72 hours, RTC or ER sooner if red flags occur .

Explanation: The total time for this visit was 25 minutes (in the range of a level 3 visit), so it can't be coded as a level 4 using total time. The time also was not documented in the note, which would be required to support coding based on total time. However, here's the breakdown for coding the visit based on MDM:

Was there a level 4 problem? Yes: acute illness with systemic symptoms.

Was level 4 data ordered/reviewed? No: two lab tests reviewed (three are required).

Was level 4 risk managed? Yes: prescription drug management.

Two out of three criteria meet the requirements for a level 4, so code it as a level 4.

Subjective: 23 y/o female presents for recheck of depression, also complaining of sore throat and ankle sprain .

Counseling going well. Started on sertraline 50 mg 4 months ago. No new stressors. Pt denies depressed mood, insomnia, anorexia, loss of pleasure, suicidal ideation, poor concentration, or irritability. Anxiety is also well controlled .

Has 2 day hx of L lateral ankle pain. Tripped over dog and turned ankle in. Pt able to walk now with mild limp .

Has a 3 day hx of sore throat, fever, and fatigue. Denies other symptoms .

Objective: T 100.4, P 88, R 14, BP 125/70. Pt is NAD, affect is bright, eye contact is good. EYES: Fundi benign. PERRLA. TMs: Benign. PHARYNX: tonsils 2+ red s exudate. NECK: Benign. No cervical adenopathy. HEART: RRR. LUNGS: Clear. Bilateral ankle exam: L ant drawer is negative, inversion testing on L causes pain, focal mild tenderness and swelling just below L lat malleolus .

Laboratory: strep screen – negative, strep culture – pending .

Assessment/Plan: Depression with anxiety F41.8 well controlled. Sertraline 50 mg refilled. Continue counseling. Discussed depression .

Tonsillitis J03.90. Strep screen neg. Discussed symptomatic measures. Will call if strep culture is positive .

Sprain left ankle, initial encounter S93.492A, is mild and improving. Discussed RICE protocol and NSAIDS if needed .

RTC 2 mo to recheck depression. Call or RTC sooner if problems or concerns develop .

Total time: 35 minutes. This includes time spent with the patient, but also time spent before the visit reviewing the chart and time after the visit documenting the visit, etc .

Explanation: The total time for this visit (35 minutes) is in the range of a level 4 (30–39 minutes), so a physician could code it as a level 4 using total time. However, here's the breakdown for MDM:

Was there a level 4 problem? No: One stable chronic illness, one acute uncomplicated illness, and one acute uncomplicated injury.

Was level 4 data ordered/reviewed? No: two lab tests.

This visit only meets one out of three criteria, so it can't be coded as a level 4 based on MDM. But because the physician has documented that the visit met the criteria for a level 4 based on total time, it can be coded as a level 4.

Subjective: 47 y/o male presents for a BP recheck. His home blood pressures have been averaging 155/95. He denies chest pain, fast heart rate, headache, flushing, or nose-bleeds. Feels good. Taking losartan every day. Watches his wt and exercises .

Objective: T 97.2, P 72, R 16, BP 160/95. NAD.

EYES: Fundi nl. PERRLA. TMs: nl .

PHARYNX: nl. NECK: Benign. Thyroid is not enlarged. HEART: S1 and S2 no murmurs. LUNGS: Clear. ABDOMEN: No masses or organomegaly. EXTREMITIES: no edema .

Assessment/Plan: Essential hypertension I10. Increase losartan to 100 mg per day. Check BP 3 times a wk, avoid salt, continue to limit alcohol to 2 drinks a day or less. RTC for BP check in 3 wks, sooner if problems arise .

Explanation: Total time for this visit was 20 minutes (but not documented in note). That is in the range of a level 3 visit, not a level 4.

Here's the breakdown for coding the visit based on MDM:

Was there a level 4 problem? Yes: One chronic, uncontrolled illness.

Was level 4 data reviewed/ordered? No: No tests were ordered.

Was level 4 risk managed? Yes: Prescription drug management.

Two out of three criteria were met, so code it as a level 4.

(Templates to help code visits based on total time or MDM are available with “ Countdown to the E/M Coding Changes ,” FPM September/October 2020.)

HOW DOES YOUR LEVEL 4 CODING COMPARE?

Comparing your coding with national averages is a good way to gauge where you stand in terms of getting the reimbursements you deserve. The national average for family physicians' usage of the level 4 code (99214) is slowly increasing and is approaching 50% of established patient office visits (it's now above 50% for our Medicare patients). 2

That's a good benchmark. But all practices are different, and some coding variation is normal. In general, doctors with more elderly patients usually have a higher percentage of level 4 visits. Doctors who address fewer problems per visit, have a high patient volume, or have a younger panel tend to have a lower percentage of level 4 visits.

Coding should be easier with the removal of the history and exam components, allowing us to focus more on treating our patients. By using the three questions presented in this article, as well as the patient examples, you should be able to more confidently code level 4 visits and make sure you're getting paid for the amount of work you're doing.

Hill E. How to get all the 99214s you deserve. Fam Pract Manag . 2003;10(9):31-36.

Marting R. 99213 or 99214? Three tips for navigating the coding conundrum. Fam Pract Manag . 2018;25(4):5-10.

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