Evaluation & Management (E/M) Services

This section covers the fundamental guidelines for billing Evaluation and Management (E/M) services, based on the major updates that began in 2021 and were extended through 2023. Proper understanding of these rules is essential for accurate coding and documentation.

Key Concepts for E/M Coding (2024 Updates)

The current E/M coding structure for office/outpatient visits simplifies code selection by focusing on two key components. For codes 99202-99215, you choose the level of service based on either Medical Decision Making (MDM) or Total Time.

1. Selecting Level by Medical Decision Making (MDM)

Medical Decision Making reflects the cognitive effort required to diagnose and manage a patient's condition. There are four levels of MDM: Straightforward, Low, Moderate, and High.

To determine the level of MDM, you must meet or exceed the requirements in at least two of the following three elements:

Element Description
Number and Complexity of Problems Addressed The nature of the patient's presenting problem(s), from self-limited to acute, chronic, or unstable.
Amount and/or Complexity of Data Reviewed and Analyzed

This includes:

  • Reviewing tests, documents, or obtaining history from others.
  • Independent interpretation of tests (not separately billed).
  • Discussion with external physicians or other qualified professionals (not separately billed).
Risk of Complications and/or Morbidity or Mortality The risk associated with diagnostic procedures and treatment decisions made during the encounter.

 

Note: Code 99211 does not require MDM. Code 99281 (ER) is also excluded.

2. Selecting Level by Total Time

Time can be used as an alternative to MDM for code selection. When using time, it is defined as the total time spent on the patient's care on the date of the encounter.

This includes:

  • Face-to-face time with the patient and/or family.
  • Non-face-to-face time spent by the provider on that day (e.g., reviewing records, documentation, ordering tests, coordinating care).

Important 2024 Change: CPT® has replaced time ranges with a single, minimum time for each code. You must meet or exceed this time to bill the code.

Office/Outpatient E/M Code Levels (2024)

Patient Type CPT Code MDM Level Total Time (Must Meet or Exceed)
New 99202 Straightforward 15 minutes
New 99203 Low 30 minutes
New 99204 Moderate 45 minutes
New 99204 High 60 minutes
Established 99211 N/A 5 minutes
Established 99212 Straightforward 10 minutes
Established 99213 Low 20 minutes
Established 99214 Moderate 30 minutes
Established 99215 High 40 minutes

 

Documentation Requirements

While the history and exam are no longer used to determine the code level, a medically appropriate history and/or examination must still be performed and documented. Your note should reflect the medical necessity of the visit and support the level of MDM or time billed.

Key Components of an E/M Note:

  • Chief Complaint (CC)
  • History of Present Illness (HPI)
  • Medically Appropriate History and/or Exam
  • Medical Decision Making (MDM) - Document the problems, data reviewed, and risk to justify the level of care.
  • Time - If billing based on time, you must document the total time and a summary of how the time was spent.

Combining E/M and OMT Services

When a significant, separately identifiable E/M service is performed on the same day as OMT, both services can be billed.

  • Report the appropriate E/M code (99202-99215) and the appropriate OMT code (98925-98929).
  • Append Modifier -25 to the E/M code to indicate that it was a distinct service from the OMT procedure.

Helpful Resources

  • Medical Decision Making (MDM) Reference Guide (PDF Download) - A handy one-page guide to MDM levels.
  • CMS Physician Fee Schedule Look-Up - Verify codes, relative values, and policies.
  • Definitions & Documentation Tips - Review key terms like "New Patient" and "Group Practice."
  • Need Expert Help? The AAO's partner, Sunrise2Sunrise (SR2), can assist with complex E/M coding questions and appeals. Contact the AAO for more information (fees may apply).