The website may be down at times on Saturday, December 14, and Sunday, December 15, for maintenance. 

    •

    Coding for Evaluation and Management Services: Answers to Common Questions

    Evaluation and management (E/M) services are at the core of most family medicine practices and represent a category of Current Procedural Terminology (CPT) codes used for billing purposes. There are different levels of E/M codes, which are determined by the physician’s or qualified health professional (QHP)’s medical decision-making (MDM) or time involved.

    You can maximize payment and reduce the stress associated with audits by understanding how to properly document and code for E/M services. 

    Jump to a section on this page:  E/M Coding Changes | Total Time | Medical Decision-Making | Other Questions 

    E/M Coding Changes

    In response to advocacy from the AAFP and other medical specialty societies, the CPT Editorial Panel revised the office visit E/M documentation and coding guidelines in January 2021. As part of the continued effort to simplify documentation requirements and reduce burden, the CPT Editorial Panel revised the E/M documentation guidelines for several other E/M services in January 2023. The 2023 changes are largely an expanded application of the 2021 office visit E/M guideline changes. In 2024, add-on code G2211 is available to provide additional payment to primary care physicians for the high-value, complex, continuous visits they provide patients.

    Major highlights of the changes include:

    1. New code G2211: The Centers for Medicare & Medicaid Services (CMS) created Healthcare Common Procedure Coding System add-on code G2211 to better account for the resource costs associated with visit complexity inherent to primary care and other longitudinal care. Learn when and how to use G2211.
    2. History and physical exam elements have been eliminated (when not appropriate): The patient history and physical exam elements are no longer components of E/M code level selection. Physicians should still document the history and physical exam as medically appropriate. These elements may still be necessary for clinical practice, professional liability (i.e., malpractice) reasons, and quality measurement.
    3. Revisions to the MDM table: The MDM table has been revised to more appropriately reflect the cognitive work required for evaluation and management services.
    4. Expanded definition of time: The definition of time for many E/M services is no longer restricted to time spent counseling the patient. Physicians can now use total time to select the level of service. Total time includes all physician or QHP time (both face-to-face and non-face-to-face) spent in care of the patient on the day of the encounter.

    See the additional FAQ sections on this page for more details on selecting E/M codes by total time or MDM.

    The updated 2021 and 2023 guidelines apply to:

    • office or other outpatient services
    • inpatient and observation care services
    • consultations
    • emergency department visits
    • nursing facility services
    • home and residence services
    • prolonged services

    The AAFP offers the following articles, videos, and tools to help you navigate 2021 and 2023 changes to the E/M services codes:

    2021 E/M coding office and outpatient resources

    General AAFP resources for E/M coding changes

    Additional resources

    Total Time FAQs

    Generally, it's appropriate to use total time to select the level of service for a patient encounter when the amount of time the physician or other QHP spends on the date of the encounter performing visit-related activities before, during, and after the visit exceeds the MDM involved.

    Time includes all activities (both face-to-face and non-face-to-face) related to the encounter performed by the physician or QHP on the date of the encounter. This includes activities such as reviewing external notes/tests/etc. not separately reported (billed), performing an examination, counseling and educating the patient/caregiver, and documenting in the medical record. Time spent performing activities normally completed by ancillary staff should not be included, and neither should travel time.

    The only time that can be included in the calculation of total time is the time personally spent by the physician or QHP on the date of the encounter. Again, ancillary staff time cannot be counted; this includes medical assistants, patient care technicians, licensed vocational nurses, licensed practical nurses, etc. Any activities that occur on a separate date cannot be counted. For example, if you were to complete your documentation the day after the face-to-face encounter, that time could not be included when selecting the level of service.

    Time related to activities that are reported separately (e.g., X-rays, lab tests, stress tests, etc.) should not be counted toward total time.

    Total time on the date of the encounter may be used alone to select the appropriate code level for the following E/M services:

    • Office visit services (CPT codes 99202-99205, 99211-99215)
    • Inpatient and observation care services (CPT codes 99221-99223, 99231-99233)
    • Hospital inpatient or discharge services (CPT codes 99234-99236, 99238-99239)
    • Consultation services (CPT codes 99242-99245, 99252-99255)
    • Nursing facility services (CPT codes 99304-99306, 99307-99310, 99315-99316)
    • Home or residence services (CPT codes 99341-99345, 99347-99350)

    Time cannot be used to select the level of service for emergency department visits. The level of service is based on MDM. This does not differ from the previous guideline. However, the MDM levels have been modified to align with those for office visits (see below).

    Time may be used to select the level of service regardless of whether counseling dominated the encounter. The definition of time consists of the cumulative amount of face-to-face and non-face-to-face time personally spent by the physician or other QHP in care of the patient on the date of the encounter. It includes activities such as:

    • Preparing to see the patient (e.g., review of tests);
    • Obtaining and/or reviewing separately obtained history;
    • Ordering medications, tests or procedures;
    • Documenting clinical information in the electronic health record (EHR) or other records; and
    • Communicating with the patient, family, and/or caregiver(s).

    Time spent in activities normally performed by clinical staff (e.g., time spent by nursing or other clinical staff collecting a patient’s history) should not be counted toward total time. Furthermore, time spent on a date other than the date of service should not be counted toward total time.

    For example, completing documentation on the day after the encounter would not be counted toward the total time when selecting the level of service for the encounter.

    Finally, time spent on services that are separately reportable (e.g., independent interpretation and reporting of test results, tobacco cessation counseling) should not be included in total time calculations.

    Each code has a specific time range. Physicians should ensure they document the total time spent on the date of the encounter in the patient’s medical record. Physicians should avoid documenting using time ranges and instead document specific total time spent on activities on the date of the encounter. 

    No, only the time personally spent by the physician can be counted toward total time. Since a scribe works in tandem with the physician during the encounter, the physician is getting credit for documenting in the record. The AMA is clear that any activities by ancillary staff should not be counted toward total time.

    Any time spent on activities that are reported separately would need to be subtracted from total time used to select the level of E/M service. For example, if you spend 20 minutes conducting an annual wellness visit and a total of 50 minutes on activities for the encounter, you will only count 30 minutes toward the E/M portion of the encounter. A separate documented encounter is needed to reflect a separately identifiable service, because the 25 modifier may be needed for the E/M service. Ensure your documentation fully supports the medical necessity of both services reported.

    There is no official guidance on what needs to be documented for total time. Your documentation should be sufficient to support the level of service billed. It is best to document the activities related to the encounter along with a statement that includes the total time for the encounter. Try to avoid providing a “cut-and-paste” generic statement of time because that is a red flag for auditors. Be specific about the services you performed for this patient.

    A split or shared visit is when a physician and other QHP act as a team in providing care for the patient, working together during a single E/M service. If the physician or other QHP performs a substantive portion of the encounter, the physician or other QHP may report the service.

    When providing a split or shared visit, the time personally spent by the physician and QHP on the date of the encounter is summed to select the appropriate level of service. However, only distinct time should be counted. When there is overlapping time (e.g., jointly meeting with or discussing the patient) only count the time of one individual. When code selection is based on total time on the date of the encounter, the split or shared service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service.

    Additionally, and as noted above, time spent on activities reported separately cannot be included in the total time used to select the level of E/M service. In those instances, you should include a statement specifying the total time does not include time spent on such services. For example, for an encounter that included the removal of a skin tag, you could include a statement such as, “Removal of the skin tag from the patient’s right armpit took 16 minutes. It was not included in the total time of the visit and was billed separately.”

    Finally, do not use standard or template times for your documentation because that can be a red flag for auditors. For example, do not document that each Level 3 encounter lasted exactly 20 minutes or that each encounter included 15 minutes related to documenting in the EHR. Your documentation should reflect the actual time spent for each encounter.

    No, the rules for teaching physicians have not changed. Only the time personally spent by the teaching physician and related to the encounter can be included in the calculation of total time.

    The CPT Panel made additional modifications to the prolonged services codes. Prolonged services codes may only be used when total time has been used to select the level of service.

    The revised prolonged services codes are listed below:

    • +99417 (Prolonged outpatient 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)
    • +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)

    Prolonged services with direct patient contact (except with office or other outpatient services) CPT codes (99354, 99355, 99356, and 99357) have been deleted.

    Medicare does not cover CPT codes 99417 and 99418, and as of January 1, 2021, it no longer covers prolonged services without direct patient contact CPT codes 99358 and 99359. Instead, physicians can report prolonged services for Medicare patients using the following HCPCS codes:

    • G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure; each additional 15 minutes by the physician or QHP, with or without direct patient contact)
    • G0316 (Prolonged hospital inpatient and observation care evaluation and management service(s) beyond the total time for the primary service; each additional 15 minutes)
    • G0317 (Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service; each additional 15 minutes)
    • G0318 (Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service; each additional 15 minutes)

    Like CPT codes 99417 and 99418, HCPCS codes G2212, G0316, G0317, and G0318 can only be used when time is used to select the level of service. They are add-on codes to and may only be used for increments of at least 15 minutes.

    The difference between the CPT codes for prolonged services and the HCPCS codes is the time threshold that must be exceeded before the code can be reported. HCPCS codes G2212, G0316, G0317, and G0318 can only be reported once the maximum time for the highest level of service has been exceeded by at least 15 minutes. 

    Medical Decision-Making FAQs

    MDM is the reflection of complexity in establishing a diagnosis, assessing the status of a condition and/or selecting a management option. The revised MDM table focuses on the cognitive work related to the diagnosis and assessment of a patient’s condition. Physicians should document the thought processes, including treatment options considered but not selected, that contribute to their diagnosis and treatment plan for the patient. 

    To qualify for a level of MDM, two of the three elements for that level must be met or exceeded.

    Number and complexity of problems addressed at the encounter

    The 1995/1997 MDM elements relied on the number of diagnoses without addressing the complexity of the patient’s condition. The revised MDM table accounts for the complexity of problems addressed during the encounter, rather than just the number of diagnoses. Diagnoses that are not made or addressed during the encounter and that do not contribute to the physician’s MDM process should not be included in selecting the level of MDM.

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

    Physicians should include labs and tests that were pertinent to the encounter and contributed to the MDM for the encounter. Data that did not impact the assessment and treatment of the patient does not need to be copied into the note. Labs/tests are defined by their corresponding CPT codes. As such, a panel would be considered one lab for the purposes of this category.

    Risk of complications and/or morbidity or mortality of patient management

    A variety of elements contribute to the risk of complications and/or morbidity or mortality of patient management. Examples include but are not limited to prescription management, social determinants of health, and decisions regarding surgery. Options considered but not selected should be appropriately documented and included when determining the risk.

    A full table of levels and elements of MDM is available from the AMA.

    Yes, these tests are results-only tests that do not require separate interpretation and can be counted as ordered or reviewed as part of the data in MDM. This includes tests that were reported separately by the physician reporting the E/M service. The test would count as one data element—it could not be counted once as an order and again as a review of results.

    Tests that require independent interpretation and report, such as X-rays, may not be used as data elements for MDM if the physician is reporting the test separately. However, as noted below, if the physician receives the test results from another physician (e.g., the radiologist who interpreted the X-ray), the physician providing the E/M service may count the review of those results as part of MDM. 

    No, not if these tests were separately billed. Tests that have an interpretive component and are reported separately cannot count toward the MDM. Point-of-care testing does not have an interpretive value, meaning there does not need to be a formal report of the findings in the medical record. The results of point-of-care tests are immediate. The physician would use the result of the point-of-care test in MDM during the same encounter at which the test ordered. However, if a physician receives the results from another physician (e.g., a cardiologist), the review of records may be counted as a unique source when selecting the level of service based on MDM.

    No, if the lab was ordered and reviewed at a previous encounter, it cannot count toward the MDM at a subsequent encounter. It is presumed that a test is analyzed when the results are reported. 

    If a test is ordered, on the same date as an office visit encounter, this falls under Category 1 Data Points in the MDM table. If the results are relayed to the patient at a return office visit or "subsequent encounter," CPT instructs that the Data Point you received credit for on the date of the order, includes the result. The order of the test, irrespective of when the results are given to the physician, includes both the order and the review of the test under Category I of the Amount and/or Complexity of Data to be Reviewed and Analyzed. To attempt to get credit for the order of the test and then the review, at a separate encounter, is considered double-dipping.

    Tests ordered outside of an encounter may be counted in the MDM at the subsequent encounter when the results are reviewed. For example, if a physician reviews a patient’s test results and orders additional tests based on those results, the review of the additional tests would be counted at the next visit because they were not counted in any previous encounter.

    No, all the information from the unique source would be counted as one data element under Category 1 of “Amount and/or Complexity of Data.” This is clarified in the AMA CPT E/M coding revision FAQs: “A unique source is defined as a physician or QHP in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.” (Emphasis added)

    No, only problems addressed during the encounter can be included in the number and complexity of problems addressed. For example, if a patient has well-controlled diabetes and is in the office for an acute visit for conjunctivitis, only the conjunctivitis would be counted toward MDM because the patient’s diabetes was not addressed during the encounter. However, if a patient asked for a referral for joint injections for chronic knee pain, but due to the patient’s diabetes status the physician determined that physical therapy would be a better option, the diabetes diagnosis can be counted because it was “addressed” in the MDM.

    Yes, if the physician documents it appropriately. The physician must document what the refill is for, whether any adjustments were made to the medication dosage, and that the medication is related to the problem being addressed at the encounter. If a medication is being continued without changes, the physician must document how the prescription is related to the condition being addressed at the encounter as well as a brief statement on management. 

    No, there must be a documented reason for the independent historian. The patient’s preference that a spouse provide the history rather than the patient does not add anything to the data point for independent historian. In this instance, it may make sense to select the level of service using total time. For example, if the physician allows the patient to call a spouse to relate the information, the time spent contacting the spouse and obtaining the history may make the encounter longer than usual. If total time is used to select the level of service for this visit, the documentation should clearly reflect the situation and why it resulted in a longer visit.

    No, the level of service reported must be supported by total time personally spent by the physician on the date of the encounter or MDM. The number and complexity of problems addressed at the encounter is only one element of the MDM table. When selecting the level of service based on MDM, two of the three elements must be met or exceeded.  

    Beginning in 2024, the physician or QHP may determine who performed the substantive part of a visit using either total time or MDM. According to the 2024 CPT® Professional Edition,

    “…performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM. If the amount and/or complexity of data to be reviewed and analyzed is used by the physician or other QHP to determine the reported code level, assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other QHP, because the relevant items would be considered in formulating the management plan. Independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other QHP if these are used to determine the reported code level by the physician or other QHP.”

    Other E/M Coding FAQs

    Yes, both Medicare and private payers have adopted the new guidelines. Additionally, adoption of the increased values will vary based on a physician’s contract with the payer. Physicians should contact their local provider relations representatives to discuss incorporating the increased values into their contracts.

    There’s no specific guidance to determine which method to use. You should use the method that most appropriately captures the work performed during the encounter. For example, for an encounter during which the patient had many questions and the level of MDM was lower, it may make more sense to select the level of service using time. Conversely, if an encounter was brief but required a higher level of MDM, it may be appropriate to select the level of service using MDM. Whichever method you use, include sufficient documentation to justify the level of service billed. Additionally, document based only on the method you used; do not document both time and MDM for the same encounter, because this could confuse auditors.

    Many private payers have implemented downcoding programs, where the payer lowers the level of service submitted on the claim. Payers most frequently downcode claims with a higher level of E/M service when the payer believes the diagnosis submitted does not warrant the level of service billed by the physician. Some payers have instituted claim edits that automatically downcode the claim without first requesting documentation from the physician. The AAFP has and continues to advocate with payers to provide clear communication and education to physicians regarding downcoding programs. Specifically, the AAFP advocates that payers provide transparency into any program whereby physicians may be identified as outliers. The AAFP also advocates for simplified appeals processes and for appeals to be processed in a timely manner. The American Medical Association developed a guide to payer E/M downcoding programs (Payer E/M downcoding programs: what you need to know). 

    Medicare increased the relative value units of many E/M codes in conjunction with the associated descriptor and documentation changes. Physicians can look up the current values and allowed amounts using the Medicare Physician Fee Schedule Lookup Tool.

    Popular coding products


     

    Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.