Key Takeaways
- E/M codes (99202-99499) describe patient encounters where a provider evaluates and manages a patient's condition — they are the most commonly reported CPT codes.
- Since the 2021 E/M changes, office/outpatient E/M code selection (99202-99215) is based on either Medical Decision Making (MDM) or total time.
- Medical Decision Making has three key elements: number and complexity of problems, amount/complexity of data reviewed, and risk of complications/morbidity/mortality.
- New patient office visits (99202-99205) require all three key components in the pre-2021 system, but now use MDM or time like established patients.
- Established patient office visits (99211-99215) are for patients seen by the same provider (or same specialty/group) within the past 3 years.
- Time-based coding uses the total time on the date of the encounter, including face-to-face and non-face-to-face activities (documentation review, care coordination, etc.).
- Hospital inpatient and observation E/M codes (99221-99223 for initial, 99231-99233 for subsequent) still use the traditional three-component system (history, exam, MDM).
- Consultation codes (99241-99245 outpatient, 99251-99255 inpatient) require a request from another physician, a rendered opinion, and a report back to the requesting physician.
Evaluation & Management (E/M) Coding
E/M codes are the most commonly reported CPT codes and represent approximately 30% of the CPC exam content. Understanding E/M code selection is essential for every medical coder.
E/M Code Categories
| Category | Code Range | Setting |
|---|---|---|
| Office/Outpatient — New | 99202-99205 | Provider's office, new patient |
| Office/Outpatient — Established | 99211-99215 | Provider's office, established patient |
| Hospital Inpatient — Initial | 99221-99223 | Initial hospital admission |
| Hospital Inpatient — Subsequent | 99231-99233 | Follow-up during hospital stay |
| Hospital Inpatient — Discharge | 99238-99239 | Discharge day management |
| Observation | 99221-99223 (initial), 99224-99226 (subsequent) | Observation status |
| Consultations — Outpatient | 99241-99245 | Office/outpatient consult |
| Consultations — Inpatient | 99251-99255 | Hospital consult |
| Emergency Department | 99281-99285 | ED visits |
| Critical Care | 99291-99292 | Critically ill/injured patients |
New Patient vs. Established Patient
The distinction between new and established patients is critical for code selection:
- New patient: Has NOT received any professional services from the physician (or another physician of the same specialty in the same group practice) within the past 3 years
- Established patient: HAS received professional services from the physician (or same specialty/same group) within the past 3 years
Key Rule: The "3-year rule" applies to the individual physician AND to any physician of the same specialty within the same group. If Dr. Smith (orthopedics) in ABC Medical Group saw the patient 2 years ago, and Dr. Jones (orthopedics) in the same group sees the patient today, the patient is established for Dr. Jones.
2021 E/M Changes: Office/Outpatient Visits (99202-99215)
The 2021 E/M guidelines significantly changed how office/outpatient visit codes are selected. Under the new framework:
Code Selection Methods (Choose ONE)
- Medical Decision Making (MDM) — Based on the complexity of the clinical decision-making process
- Total Time — Based on the total time spent on the date of the encounter
Medical Decision Making (MDM) Framework
MDM has three elements, and 2 out of 3 must meet or exceed the level to qualify for the code:
| Element | What It Measures |
|---|---|
| Number and complexity of problems addressed | How many problems and their severity (self-limited, chronic, acute, new problem with additional workup, etc.) |
| Amount and/or complexity of data to be reviewed and analyzed | Labs, imaging, external records, independent interpretation, discussion with external providers |
| Risk of complications and/or morbidity or mortality | Risk associated with the problem(s), diagnostic procedures, and management options selected |
MDM Levels for Office/Outpatient Visits
| E/M Code | MDM Level | # of Problems | Data | Risk |
|---|---|---|---|---|
| 99211 | N/A | May not require physician presence | — | — |
| 99202/99212 | Straightforward | Minimal (1 self-limited problem) | Minimal or none | Minimal risk |
| 99203/99213 | Low | Low (2+ self-limited or 1 stable chronic) | Limited (order/review tests) | Low risk (OTC drugs, minor surgery with no risk factors) |
| 99204/99214 | Moderate | Moderate (1+ chronic with exacerbation, 2+ stable chronic, 1 undiagnosed new problem) | Moderate (order/review tests + independent interpretation or external records) | Moderate risk (prescription drug management, minor surgery with risk factors) |
| 99205/99215 | High | High (1+ chronic illness with severe exacerbation, or 1 acute/chronic illness posing threat to life/function) | Extensive (independent interpretation + discussion with external physician) | High risk (drug therapy requiring intensive monitoring, decisions about hospitalization, emergency surgery) |
Time-Based E/M Coding
Under the 2021 guidelines, total time on the date of the encounter can be used to select the E/M level instead of MDM:
| E/M Code (New) | E/M Code (Established) | Total Time |
|---|---|---|
| 99202 | 99212 | 15-29 minutes |
| 99203 | 99213 | 30-44 minutes |
| 99204 | 99214 | 45-59 minutes |
| 99205 | 99215 | 60-74 minutes |
What Counts as Time
- Face-to-face time with the patient (history, exam, counseling)
- Non-face-to-face time on the date of the encounter: reviewing records, ordering/interpreting tests, documenting, care coordination, communicating with other providers
- Time does NOT need to be face-to-face
Prolonged Services
If time exceeds the highest-level code range, report the highest E/M code PLUS add-on code 99417 for each additional 15-minute increment:
- 99205/99215 (60-74 min) + 99417 (each additional 15 min)
Consultation Codes (99241-99255)
A consultation has three mandatory requirements (the "3 Rs"):
- Request: Another physician must request the consultant's opinion (documented in the record)
- Render: The consultant must evaluate the patient and render an opinion/advice
- Report: The consultant must send a written report back to the requesting physician
Important CPC Exam Points:
- Medicare does NOT recognize consultation codes — consults are reported using new/established patient visit codes for Medicare
- Many private payers DO recognize consultation codes
- The CPC exam tests consultation code selection per CPT guidelines
- If the consultant takes over management of the patient's care, subsequent visits are billed as established patient visits, not ongoing consultations
Critical Care Codes (99291-99292)
Critical care is provided to critically ill or injured patients with conditions that involve a high probability of life-threatening deterioration:
| Code | Time | Description |
|---|---|---|
| 99291 | 30-74 minutes | Critical care, first 30-74 minutes |
| 99292 | Each additional 30 minutes | Add-on code for each additional 30 min |
- Critical care is time-based and does NOT require continuous bedside presence
- Time must be documented and does NOT need to be consecutive
- The provider must be immediately available and directly engaged in the patient's care
- Bundled services (interpretation of EKGs, chest X-rays, blood gases, etc.) are included and NOT separately reportable
Under the 2021 E/M guidelines, how is the level of an office visit (99202-99215) determined?
A physician manages a patient with Type 2 diabetes with a new exacerbation, orders and reviews lab work, and prescribes a new medication requiring monitoring. Based on MDM, which E/M level is most appropriate?
What are the "3 Rs" required for a consultation code?
A patient was last seen by Dr. Adams (internal medicine) at City Medical Group 2 years ago. Today the patient sees Dr. Baker (internal medicine) at the same group. Is this patient new or established for Dr. Baker?
Which of the following activities count toward "total time" for E/M code selection under the 2021 guidelines? (Select all that apply)
Select all that apply
Critical care code 99291 covers the first ___ to ___ minutes of critical care on a given date.
Type your answer below