Billing & Coding


Evaluation and Management (E/M) Services

In 2023 the CPT Editorial Panel approved additional revisions to the rest of the E/M code section to provide continuity across all the E/M sections allowing for the revisions implemented in the E/M office visit section in 2021 to extend to all other E/M sections.

History and/or Examination

E/M codes that have level of services include a medically appropriate history and/or physical examination, when performed.

Levels of E/M Services

Select the appropriate level of E/M services based on the following:

  1. The level of the Medical Decision Making (MDM) [PDF download] as defined for each service, or
  2. The total time for E/M services performed on the date of the encounter.

Guidelines for Selecting Level of Service Based on Medical Decision Making

There are four types of Medical Decision Making (MDM) [PDF download]: straightforward, low, moderate, and high. MDM does not apply to code 99211, 99281.

MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. There are three elements to consider when choosing the level of MDM.

  • The number and complexity of problem(s) that are addressed during the encounter.
  • The amount and/or complexity of data to be reviewed and analyzed. These data include medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. Data is divided into three categories:
    • Tests, documents, orders, or independent historian(s).
    • Independent interpretation of tests (not separately reported)
    • Discussion of management interpretation with external physician or other qualified health care professional or appropriate source (not separately reported)
  • The risk of complications and/or morbidity or mortality of patient management. This includes decisions made at the encounter associated with diagnostic procedure(s) and treatment(s)

Guidelines for Selecting Level of Service Based on Time

When time is used for reporting E/M services codes, the time defined in the service descriptors is used for selecting the appropriate level of service.

For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the date of the encounter.

Pay Attention to the Time

CPT® 2024 has removed the time ranges from both the new and established office/outpatient E/M codes and replace them with a single total time amount, which is the lowest number of minutes in the current range for each code. This time “must be met or exceeded” according to the new wording that now appears in each of the codes’ descriptors.

For example, 99202 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 has a current time range of 15-29 minutes. Beginning Jan. 1, 2024, the provider must meet or exceed 15 minutes of total service time before you can bill this code by time.


This lecture was presented by Judith O’Connell, DO, MHA, FAAO, AAO Secretary-Treasurer, during the AAO's 2021 Virtual Convocation. This lecture provides an overview of the recent history of evaluation and management revisions, reviews the updates on policy changes for Centers for Medicare & Medicaid Services (CMS) Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2021, and outlines practice cases to demonstrate how to choose the level of service. View presentation slides.


Medical Decision Making (MDM) [PDF download]
Current Procedural Terminology (CPT®)