Evaluation and Management EM of the CPT Codes (PDF)

American Medical Association (AMA)
The American Medical Association's registered trademark is CPT. American Medical Association. Copyright 2022. Every
right is retained. It should be noted that future CPT Editorial Panel (Panel) or Executive Committee actions may have an
impact on CPT codes and/or descriptions. As a result, the CPT code set's code numbers and/or descriptor language
may alter at the time of release.
- 1 -
Evaluation and Management (E/M) of the CPT® Codes
Modifications to the CPT® Code and Guidelines
This document has the following changes to CPT E/M:
as of January 1st, 2023:
• Hospital Inpatient and Observation Care Services codes 99221-99223, 99231-99239,
Consultations CPT codes 99242-9945, 99252-99255, Emergency Department
Services codes 99281-99285, Nursing Facility Services codes 99304-99310, 99315,
99316, Home or Residence Services codes 99341, 99342, 99344, 99345, 99347-
99350
• Elimination of Hospital Observation Services Electronic Medical Record (EMR)
numbers 99217-99220
• Revision of E/M CPT codes 99221-99223, 99231-99239, and recommendations for
Hospital Inpatient and Observation Care Services
• Getting rid of the E/M codes 99241 and 99251 for consultations
• Changes to Consultations E/M codes 99242-99245, 99252-99255, and guidelines
• Changes to the Emergency Department Services E/M codes 99281-99285 and the
rules for using them
• The Nursing Facility Services E/M code 99318 will no longer be used
• Changes to the Nursing Facility Services E/M codes 99304–99310, 99315, 99316,
and guidelines
• Getting rid of E/M codes 99324-99238, 99334-99337, 99339, and 99340 for
'Domiciliary, Rest Home, Boarding Home, or Custodial Care Services
Removal of E/M code 99343 for Home or Residence Services
• Modification of Home or Residence Operations E/M codes 99341, 99342, 99344,
99345, 99347-99350 and their corresponding instructions
• Prolonged Services E/M codes 99354-99357 are no longer in use.
• Guidelines for Prolonged Services E/M codes 99358, 99359, 99415, and 99416 have
been revised.
• Updates to the Prolonged Services E/M code 99417, as well as the corresponding
guidelines
• The creation of the Prolonged Services E/M code 993X0 and its corresponding
guidelines

- 2 -
Standards for Evaluating
& Managing (E/M) Services
In addition to the material discussed in the Introduction, numerous more things
specific to this part are defined or specified in this paragraph.
E/M Guidelines Review
➢ The E/M rules contain elements universal to all E/M categories and sections
exclusive to their respective categories. The vast majority of service
categories, as well as many of the subcategories, each have their own set of
rules or instructions exclusive to that category or subclass. Where they are
stated, for example, "Hospital Inpatient and Observation Care," special
instructions are supplied before the listing of the individual E/M service
codes. It is essential to review the guidelines for each category and
subcategory carefully. These recommendations are to be utilized by the
reporting physician or any other competent healthcare practitioner to identify
the appropriate level of service. These recommendations do not impose any
documentation requirements or standards of care. The primary goal of
documenting patient care is to assist present and future healthcare team
members in providing quality care to patients (s). These guidelines apply to
services that require face-to-face encounters between the patient, a family
member or caregiver, and an attendant.
Regarding cases 99211 and 99281, face-to-face services may be carried out
by clinical professionals.)
There are a lot of different code categories to choose from under the
Evaluation and Management area (99202-99499). It's possible that each
category has its own unique set of criteria or that the codes themselves
include particulars. The following types of activities are under the purview of
these E/M guidelines:
■ Consultations at Offices and Various Other Outpatient Services
■ Services for Hospital Patients Receiving Inpatient Care as Well as Observation Care
■ Consultations

- 3 -
■ Services Offered at the Emergency Department
■ Services Provided by Nursing Homes
■ Services for the Home or Private Residence
■ Extended Duration of Service Evaluation and management services can be provided
either with or without direct patient contact on the date of the service.
Evaluation and Management (E/M)
Service Types and Their Classifications
➢ The evaluation and management component are broken up into several major
categories, such as consultations, hospital inpatient or observation care visits,
and office visits. The majority of categories can each be further broken down
into two or more subcategories of E/M services. For instance, there are two
types of office visits: new patient visits and existing patient visits.
Additionally, there are two subcategories of hospital inpatient and observation
care visits (initial and subsequent). The subcategories of E/M services are
then further subdivided into tiers of E/M services, each of which is denoted
by a unique code.
➢ The core structure of E/M service coding remains the same, with different
levels determined by either the amount of time spent or the amount of medical
decision-making (MDM). To begin, there is a listing of a one-of-a-kind code
number. Second, the location of the service and/or the kind of service
provided (e.g., office or another outpatient visit). Third, the specifics of the
service's content are outlined. Fourth, a time limit has been set. (The
Guidelines for Selecting Level of Service Based on Time give a
comprehensive discussion on time.)
➢ The location of the face-to-face meeting with the patient and/or their family
or caregiver determines the sort of service provided as well as the site where
the service is provided. For instance, a service that was rendered to a resident
of a nursing home who was transported to the office should be documented
using an office code or another appropriate outpatient code.
Existing and New Patients

- 4 -
➢ Skilled professionals are those face-to-face services performed by physicians
and other certified health care professionals who may report assessment and
management services and are used solely to differentiate between new and
established patients. Patients who have not seen a doctor or other qualified
healthcare professional within the last three years are considered new
patients. This includes patients who have seen other doctors or other qualified
healthcare professionals in the same group practice but who are not in the
same specialty or subspecialty.
➢ A patient is considered to be an established patient if, within the past three
years, they have received professional services from either the doctor or
another qualified health care professional or from another doctor or skilled
health care a member of the medical community who specializes in the same
field and subfields but belongs to a different organization practice. Available
now is a decision tree that compares new patients to those who have been
seen before.
➢ When a physician or other qualified health care professional is covering for
another licensed medical practitioner or different appropriately trained health
care experience, the encounter with the patient will be coded in the same way
that it would have been coded by the physician or other qualified health care
professional who is not available. This applies whether the doctor or another
trained healthcare provider is on call for the patient or provides coverage.
When working alongside physicians, advanced practice nurses and physician
assistants are regarded to be practicing within the same medical specialty and
specialty as the supervising physician. This is because of the close
collaboration between the three professionals.
In the emergency unit, new patients are handled precisely the same as those who have been
there for a while and are considered established patients. E/M services are eligible to be
recorded under the emergency department category for any new or established patient who
presents themselves for treatment in the emergency department. The New Patients vs.
Established Patients Decision Tree is offered as a tool to determine whether or not to record
the E/M service performed as an interaction with a new patient.

- 5 -
Useful Hints for Coding
Guidelines for Utilizing the Current Procedural Terminology Codebook
When healthcare staff and physician assistants work with doctors, they are considered to be in
the same specialty and subspecialty as the doctors. A "doctor or other skilled medical
professional" is a person who has the right credentials in terms of education, training, licensure
or regulation (if applicable), and facility privileges (if applicable) and who offers expert advice
or help within the limits of his or her practice and independently reports that professional
service. "Clinical staff" is not the same as these people. A clinical staff member does their job
under the direction of a doctor or other qualified healthcare professional and is permitted to do
so by applicable laws, regulations, and the facility's operating policy; helps perform a specific
professional service but does not report that service individually. There may be additional
restrictions that govern who is allowed to report certain services.
The CPT Codebook contains all relevant information, including the CPT Coding
Guidelines, an Introduction, and Instructions for Using the CPT Codebook.
Initiation and Subsequent Provision of Services
➢ There are numerous categories that apply to both newly registered patients and those
who are already in the system (e.g., hospital inpatient or observation care). Services
are placed into one of these categories depending on whether or not the service in
question is intended to serve as the foundation for a succession of further services.
Professional services are in-person services provided by medical doctors and other
qualified healthcare professionals. These experts may record evaluation and
management services in order to differentiate between first and future visits. An initial
service is provided to a patient during their hospitalization, observation, or admission
and stay in a nursing home if they have not been seen by a doctor or any other
competent health care professional or if they have not received any professional
services from a health care provider. This can also apply if the patient has not
previously received medical or mental health care from a health care provider.
From another physician or other competent health care provider who is a part of the
same group practice and who practices the exact same specialization and specialty as
the original patient.

- 6 -
➢ If a patient has previously received professional services from a physician or another
qualified healthcare provider, then this is a subsequent service.
➢ If a physician or other qualified health care professional is covering for another
physician or other skilled health care professional, the encounter with the patient will
be categorized in the same way that it would have been classified by the physician or
other competent health care professional is not available. When advanced practice
nurses and physician assistants work alongside physicians, it is generally accepted
that they are doing duties associated with the same medical specialization and
specialty as the supervising physician.
➢ A hospital stay that involves a transfer from observation to inpatient status is
considered a single visit for the purposes of reporting hospital inpatient or
observation care services. In the context of the reporting of services provided by
nursing facilities, a stay that involves transition(s) between the levels of care
provided by a skilled nursing facility and nursing facilities is considered to be the
same stay.
Separate Reports on Services
Any method or service that can be identified by a specific CPT code and was done on
the same date as E/M services can be reported separately.
• The procedure of assessing the levels of E/M services does not consider situations in
which the professional interpretation of diagnostic tests and research is reported
independently by the physician or another qualified health care professional who is
reporting the E/M service. The reason for this is that ordering, actual performance,
and/or interpretation of diagnostic tests and studies conducted during contact with a
patient are not regarded to be part of the E/M service. Tests that are evaluated as part
of MDM but do not need a distinct interpretation (for example, tests that result only)
do not count as an independent interpretation. Instead, these tests might be regarded
as ordered or reviewed for the purpose of calculating an MDM level. In addition to
the code that corresponds to the appropriate evaluation and management service, it is
possible to individually report the results of diagnostic tests and studies for which
unique CPT codes are provided. These results can be reported alongside the code that
corresponds to the appropriate evaluation and management service. It is possible to
report separately both the interpretation of the results of diagnostic tests or studies

- 7 -
(i.e., the professional component) and the preparation of a separate distinctly
identifiable signed written report by making use of the appropriate CPT code and, if
necessary, by appending modifier 26 to the end of the code. This would be done in
order to receive separate payments for both of these services. This is done in this
manner to ensure that we are in accordance with the Medicare rules.
On the day of a treatment or service described by a CPT code, the physician or other
qualified healthcare care professional may be required to certify that the patient's
condition demanded a significant, independently identifiable E/M service. The
symptoms for which the operation and/or service was performed may have prompted
or inspired the E/M service. This situation can be indicated by adding modifier 25 to
the relevant level of E/M service. Therefore, separate diagnoses are not required when
surgery and E/M services are reported on the same day.
The History and maybe the Examination
➢ Levels of services for E/M codes that specify a medically necessary history and/or
physical examination. The reporting physician or other competent healthcare
practitioner determines the kind and depth of the patient's history and/or physical
examination service. A physician or other competent health care professional may
evaluate information collected by the care team and information provided directly by
the patient or caregiver (through an EHR portal or questionnaire, for example). These
E/M service code selections have little to do with the depth of the patient's history
and physical exam.
The Different Levels of E/M Services
Determine the right amount of E/M services to provide depending on the factors
listed below:
1. The level of the MDM according to its definition for each service, or
2. The cumulative amount of time spent on E/M services that were carried out on the
day of the encounter.
There are anywhere from three to five levels of available E/M services for reporting
reasons, and these levels may be found under each category or subcategory of E/M
service depending on MDM or time. There is no consistent equivalence between the
various categories and subcategories of service with regard to the E/M service levels.
Take, for instance, the very first.
The first level of E/M services in the office visit subcategory for new patients does
not have the same precise definition as the first level of E/M services in the office

- 8 -
visit subcategory for established patients. Every level of E/M services is available to
qualify medical doctors and other professionals working in the healthcare industry.
Medical Decision-Making Guidelines for
Service-Level Selection
➢ MDM may be broken down into the following categories:
• straightforward,
• low,
• moderate
• high.
In the cases of 99211 and 99281, the MDM level as a conceptual framework is not
applicable.
➢ Establishing diagnoses, determining the current state of a problem, and/or deciding
which treatment approach to take are all components of MDM. Three components
make up MDM's definition. The following are the components: The number and
level of difficulty of the problem(s) that are solved during the course of the
encounter.
➢ The volume of data to be examined and/or the level of complexity of the data to be
evaluated. These data may consist of a patient's medical records, test results, or other
information that has to be gathered, ordered, reviewed, and evaluated prior to the
interaction. This comprises information acquired from a variety of sources, as well as
interprofessional communications or interpretation of tests that are not recorded
individually. The act of ordering a test is considered to be part of the category of test
result(s), and the examination of the test result is considered to be an integral aspect
of the encounter rather than a separate encounter that comes later. When placing an
order for a test, you might add options that were evaluated but ultimately rejected
after being shared decision-making. For example, a patient may ask for medical
testing that's not required for their situation. In this instance, it may be required to
talk about the lack of benefits. And a test may usually be done, but because it could
be risky for a certain patient, it is not ordered. These things must be written down.
The data are split into three groups:
➢ Tests, papers, instructions, or independent historian (s). (Each test, order, or
document is counted separately to reach a certain number.)
➢ Tests that are interpreted on their own (not separately reported).

- 9 -
➢ Talking with an outside doctor, other qualified health care professional, or
appropriate source about how to treat or interpret a test (not separately reported).
➢ The risk of complications, illness, or death from how the patient is cared for. This
includes decisions made about the diagnostic procedure(s) and treatment at the time
of the visit (s). This includes the treatment options that were chosen and the ones that
were thought about but not chosen after the patient and/or family helped make the
decision. For instance, when deciding whether or not to seek medical attention, it is
important to think about other levels of care. For example, a psychiatric patient who
gets enough help in an outpatient setting or a person with advanced dementia who
has an acute condition that would usually require inpatient care but for whom
palliative care is the goal and doesn't need to be hospitalized.
Shared decision-making includes asking the patient and/or their family what they want,
educating the patient and/or their family, and explaining the risks and benefits of
different ways to treat the patient.
There is a possibility that MDM will be affected by role and management responsibilities.
► When a doctor or even other eligible health care provider is trying to report a separate
Cpt that includes interpretation and/or report, the interpretation and/or report do not count
toward the MDM when choosing a level of E/M services. This is because interpretation
and/or report are considered to be part of the reporting of the separate CPT code. If the
physician or another qualified health care professional is reporting a separate service for
discussion of management with a physician or another qualified health care professional,
then the discussion will not be considered by the MDM for choosing a level of E/M
services.
When reporting an E/M services code, the Levels of Medical Decision Making (MDM)
table, which may be found in Table 1, serves as a reference to aid in selecting the
appropriate level of MDM. The following information can be found in the table: the four
levels of MDM (i.e., straightforward, low, moderate, and high), as well as the three
components of MDM (i.e., the quantity and/or the level of difficulty of the information, as
well as how many tasks that needed to be solved during the encounter reviewed and
analyzed, and the potential for patient care to result in complications, illness, or even death.
Two of the three requirements for a given level of MDM must be satisfied or surpassed
before one can be considered qualified for that level of MDM.
The examples provided in the table may or may not be relevant to the particular care
settings described. For instance, the decision to admit a patient to the hospital applies to
outpatient or nursing facility encounters, whereas the decision to increase the hospital level

- 10 -
of care (for example, transfer to the intensive care unit) applies to a patient who is already
in the hospital or receiving observation care. Please also refer to the introductory
instructions provided in the section devoted to each code family.
Table 1: The Different Levels of Decision-Making in Medical Care (MDM)
Components of the Process of Making Medical Decisions
Grade of MDM
(Based on two
out of three
MDM Elements)
The quantity and
level of difficulty
of the issues
that were
resolved during
the encounter
The scope of the
data that has to be
examined,
including its
quantity and/or
complexity.
*Each different
assessment,
sequence, or
document
contributes to
combining a
combination of two
or three in
Category 1 below.
*Each different
assessment,
sequence, or
document
contributes to
combining a
combination of
two or three in
Category 1
below.
Straightforward Minimal = having
only one, usually
self-contained,
issue
little to none Minimal mortality
risk associated
with further
diagnostic tests
or therapy
Low Low
2 or greater self-
restraint
Restricted (Only one
category criteria must be
met).
Restricted
(Only one
category
criteria must
be met).

- 11 -
small
difficulties
or: 1 stable, long-
term illness;
or 1 mild,
moderate
sickness or
damage;
or 1 unvarying and
acute sickness;
1 acute, benign
illness or accident
needing hospital
inpatient or
observation level
therapy
Category 1: Assessments
and paper
Any two of the following
options:
according to the following:
A look back at the previous
external notice (s)
from each unique
source*;
A Discussion on the
the outcome(s) of each
unique test*;
Ranking of each in order
unique test*
or Group 2: Evaluation
needing an independent
historian (For the
categories of independent
test interpretation and
management or test
interpretation discussion,
see moderate or high).
a medical
examination or a
course of therapy
Moderate Moderate Moderate Moderate
chance of
getting sick from

- 12 -
• 1 or more
long-term
illnesses that
become
worse, get
worse over
time, or have
adverse
reactions
from
therapies;
• 1 or more
long-term
illnesses that
become
worse, get
worse over
time, or have
adverse
reactions
from
therapies;
■ (It is required that
you are successful
in at least one of
these three areas.)
■ Tests, records, or
the findings of an
impartial historian
make up Category
1. (s)
■ Choose any three
options from the list
that follows:
■ a review of the
preceding external
note(s) from each
unique source; a
review of the
result(s) of each
unique test; a
review of the
ordering of each
unique test; an
evaluation that
requires the
assistance of an
independent
historian (s)
■ alternatively,
Category 2:
Independent
Interpretation of
Tests or
Interpretation of a
Test Done
Independently
extra medical
examinations or
therapy
Only a few
illustrations:
• Medication
Administration
• Decisions on low-risk
surgical procedures
when a patient or
surgical risk
considerations are
known
• The decision to do a
major elective
operation without first
identifying the
patient's or the
procedure's risk
factors
• Significant social
barriers that stand in
the way of a

- 13 -
The decision to do a major
elective operation without
first identifying the patient's
or the procedure's risk
factors
Significant social barriers
that stand in the way of a
diagnosis or treatment
OR
Discussion of treatment or
interpretation of test results
falls under Category 3 and
includes the following:
Discussion of treatment or
interpretation of test results
with an outside physician or
other qualified health care
professional or suitable
source (not separately
recorded)
factors that
influence one's
health
High High
■ One or more
long-term
illnesses
with severe
flare-ups,
development
, or side
effects of
treatment;
Comprehensive
▪ (Must fit into at least
two of the three
categories)
Section 1: Testing,
recordings, or unbiased
historian (s)
Choose any three of the
following combinations:
high likelihood
of mortality from
subsequent
diagnostic
procedures or
treatments
Examples:
▪ Drug
treatment
that is
intensive

- 14 -
▪ or 1 acute or
chronic
disease or
injury that
endangers life
or
physiological
function
● Examination of
previous
outside note(s)
from each
distinct
source*;
● Examine the
outcome(s) of
each one of the
distinctive
tests*;
● Evaluation
calls for the
participation of
a private
historian (s)
OR
Independent analysis of
test results constitutes
Category 2
An interpretation of a test
that was carried out
independently by a different
physician or by another
competent health care
professional (which was not
separately recorded);
Discussions regarding
management or
interpretations of tests go
under Category 3.
▪ Consultation with an
external physician or
other competent health
care expert or suitable
source for the
surveillance
for toxicity
■ Choices
should be
made for
large
elective
surgeries
with known
risk
consideratio
ns for the
patient or
the
procedure
■ Concerning
the decision
to do major
emergency
operation
■ Choices
should be
made about
hospitalizati
on or an
increase in
the degree
of hospital
treatment
■ As a result
of the
patient's
dismal
prognosis,
the decision
was made
not to

- 15 -
treatment or
interpretation of tests
(which is not
separately recorded)
attempt
revive and
to reduce
the intensity
of care.
■ Parenteral
controlled
substances

- 16 -
Quantity and Difficulty of Issues Acknowledged
at the Meeting
➢ The quantity and severity of the issues that must be solved during the encounter is
taken into consideration as one of the criteria for choosing the appropriate level of
service. MDM may be impacted in a variety of ways by the simultaneous treatment
of many newly emerging or long-standing illnesses. Symptoms may congregate
around a certain diagnosis, and each individual symptom does not necessarily
indicate a separate health problem. Comorbidities and underlying diseases, in and of
themselves, are not considered when choosing a certain degree of E/M services
unless these issues are resolved, and the presence of these issues either increases the
amount of data that has to be evaluated as well as the complexity of that data
analyzed or the possibility of patient treatment resulting in complications, morbidity,
or even death. This is the case even if the comorbidities and underlying diseases are
addressed. The ultimate diagnosis of an illness does not, in and of itself, define the
complexity or danger associated with the condition. Extensive assessment may be
necessary to arrive at the decision that the signs or symptoms do not represent a very
morbid condition. Therefore, presenting symptoms that are likely to indicate a highly
morbid ailment might "drive" MDM even in cases where the eventual diagnosis is
not a highly morbid disorder. It is important that the examination and/or therapy be
appropriate for the likely underlying cause of the disease. The interplay of many
issues, each of which is of lesser severity than the others, may, in the aggregate,
generate a bigger danger.
In the context of these definitions, the word "risk" refers to the danger that stems
from the underlying ailment. The risk that comes from the disease is separate from
the risk that comes from the treatment, despite the fact that there is frequently a
correlation between the two.
The following is a list of definitions for the components of medical decision-making
(see Table 1, Levels of Medical Decision-Making):
Problem: A disease, condition, ailment, injury, symptom, sign, finding, complaint, or
other problem that is addressed during the meeting, with or without a diagnosis being
confirmed at the time of the encounter An issue can be characterized as a sickness,
condition, ailment, injury, symptom, sign, or discovery, or other matter addressed at
the encounter
The issue discussed: A problem is considered to have been addressed or managed
when the physician or another competent healthcare provider reporting the service
either evaluates or treats the problem during the contact. This includes taking into

- 17 -
account additional tests or treatments that the patient, parent, guardian, or surrogate
might not choose based on the results of a risk-benefit analysis or their own
preferences. A notation in the patient's medical record stating that the problem is
being managed by another professional without any additional assessment or care
coordination being documented does not qualify as the problem being addressed or
managed by the physician or any other qualified health care professional reporting
the service. The referral does not qualify as being addressed or handled by the
physician or other competent health care professional reporting the service since it
does not include evaluation (by history, examination, or diagnostic study[ies] or
consideration of treatment. The problem that is addressed for hospital inpatient and
observation care services is the problem status on the day of the encounter, which
may be considerably different from the problem state when the patient was admitted
to the hospital. It is an issue that the reporting physician or another trained healthcare
professional is managing or co-managing, and it may not be the reason for admission
or continuing stay.
Minor issue: A condition that may not necessitate the presence of a physician or
other competent health care professional, but the service is delivered under their
supervision (see 99211, 99281).
Self-limited or small problem: A condition that follows a clear and prescribed course
is of a transitory character and is unlikely to affect health status permanently.
➢ "Stable, chronic sickness" refers to a health condition that is predicted to last for at
least one year or until the patient passes away. In the context of determining what
constitutes chronicity, conditions are considered to be chronic regardless of whether
or not the stage or severity of the ailment varies (for example, both uncontrolled
diabetes and managed diabetes are considered to be single chronic conditions). The
unique treatment goals for a given patient are what determine what "stable" means in
the context of the MDM classification system. A patient is not considered stable if
they have not reached their treatment objective, even if their health hasn't changed at
all. and there is no immediate risk to their life or ability to function. For instance, a
patient who has continuously poor blood pressure control and for whom improved
control is a goal is not stable, even though the pressures are unchanging and the
patient's condition is not improving. Without therapy, morbidity risk is substantial.
A recent or fresh short-term issue with minimal risk of morbidity is being examined
for treatment because of its acuteness and lack of complications. The therapy carries a
little to the nonexistent risk of death, and it is anticipated that the patient will make a
full recovery without suffering any functional impairment. An acute, uncomplicated
sickness is one that does not follow a predetermined and set pattern of progression in
its resolution, despite the fact that it is often self-limiting or of a very mild nature.

- 18 -
Acute illness, simple disease, or accident: A issue that has emerged recently or
emerged for the first time in a short period of time and needs treatment while having a
minimal risk of morbidity.
Acute conditions that are relatively straightforward but nevertheless require
hospitalization and either inpatient or observation level care: A recent or new short-
term problem with a low risk of morbidity for which treatment is required. There is little to
no risk of mortality with treatment, and full recovery without functional impairment is
expected. The treatment required is delivered in a hospital inpatient or observation-level
setting.
Acute sickness that is stable: A issue that has recently surfaced or become apparent,
for which therapy has just begun. The patient's health has stabilized; nevertheless, it is
possible that the patient's symptoms will continue to improve over the next days and
weeks.
Illness that is chronic and is characterized by aggravation, progression, or
treatment-related adverse effects: a chronic illness that is acutely deteriorating, poorly
managed, or advancing with the purpose of halting the progression and needing more
supportive care or requiring attention to therapy for side effects and the necessity of
preventing the advancement.
Undiagnosed new problem with an unknown prognosis: A problem in the differential
diagnosis that reflects a circumstance that has a very good chance of leading to a high
risk of morbidity if treatment is not administered.
Acute sickness, characterized by the presence of systemic symptoms: is defined as a
condition that, in the absence of treatment, carries a high risk of leading to morbidity.
See the definitions of a self-limited or minor problem, acute, uncomplicated illness or
injury, and general systemic symptoms, such as fever, body aches, or fatigue, that may
be treated to alleviate symptoms in a minor illness. These symptoms, along with others
like them, maybe treated to alleviate symptoms. Systemic symptoms might refer to a
specific system rather than the body as a whole.
acute pain, complex accident: An injury that necessitates treatment and/or
examination of bodily systems not immediately related to the injured organ, is
severe, has several treatment choices, and/or has a risk of morbidity.
Illness that is prolonged and is characterized by significant exacerbations,
progression, or treatment-related adverse effects: The severe worsening or
progression of a chronic illness or the severe adverse effects of treatment, both of
which carry a considerable risk of morbidity and may call for an increase in the level
of care being provided to the patient.

- 19 -
Acute or long-term disease or damage that places a person's life or their capacity
to function properly inside the body in danger: An acute illness with systemic
symptoms, a complicated acute accident, a persistent illness or that has worsened
and/or progressed over time, or the side effects of medicine that pose a risk to life or
bodily function in the near future. If treatment is not administered is an example of
an emergent condition. There is a possibility that some symptoms point to a sickness
that is not only very likely but also poses a risk to either one's life or their bodily
functions. It is possible to put them in this category if the examination and therapy
are suitable for this level of potential severity.
Data volume and/or complexity to be examined
and interpreted
➢ The quantity and/or the complexity of the data that has to be examined or evaluated
during an encounter is one factor that is considered in the selection of the level of
services.
The method of making use of the data as a component of the MDM is analyzed. Although
the data piece itself may not be susceptible to analysis (for example, glucose), it is still
included in the mental processes that are utilized when diagnosing, evaluating, or treating a
patient. When findings are presented, it is assumed that any tests that were requested were
also performed and evaluated. Therefore, whenever they are ordered during the course of a
confrontation, they will count toward that confrontation. The encounter in which the results
of tests that were ordered outside utilized an encounter were examined might count toward
the encounter total. When there is a recurrent order, each newly obtained result can be
recorded in the encounter in which it was obtained. examined if the order keeps coming
back. An encounter that includes an order for monthly prothrombin times, for instance,
would be counted as one prothrombin time ordered and reviewed. Similarly, a prothrombin
time review would count as one prothrombin time ordered. If more future outcomes are
evaluated in a subsequent encounter, then that subsequent encounter might count those
additional future findings as a single test. The professional component of any service for
which whomever, among physicians or other trained medical personnel, is responsible for
reporting the E/M. services separately report it is not counted as a data element ordered,
reviewed, analyzed, or independently interpreted for the purposes of determining the level
of MDM. This applies to any service for which the professional component is reported.
Imaging, laboratory, psychometric, or physiologic data might all be included in a test. Tests
A clinical laboratory panel (e.g., basic metabolic panel [80047]) is a single test. The CPT

- 20 -
code set defines the distinction between a single test and several tests in line with its
specifications. Pulse oximetry is not considered a test for the purpose of the data that was
examined and evaluated.
Unique: A unique test is described by the CPT code set. When several results of the same
unique test (e.g., serial blood glucose levels) are compared during an E/M service, count it
as one unique test. Even though they are classified with different CPT codes, tests that
include components that overlap each other are not considered to be unique. For instance, a
complete blood count with differential would include a CBC without differential as well as
a platelet count in addition to the standard set of hemoglobin. A physician or other
competent health care practitioner in a separate group or different specialization or
specialty, or a unique entity, is considered to be a unique source. A unique source may also
be an individual. The evaluation of all content derived from any particular source qualifies
as one of the MDM's components.
Combining Data Components: In order to accumulate the results of many data elements, it
is necessary to combine them. For instance, summing the results of reviewing notes,
ordering tests, and going through the results of those tests requires the use of an independent
historian. It is not necessary for each individual item type or category to be represented in
this manner. A combination of three components would consist of a one-of-a-kind test being
ordered, having a note evaluated, and using an impartial historian.
External: Records, correspondence, and test results that come from an external physician or
other certified health care provider, institution, or health care organization comes under this
domain.
The external medical or another skilled healthcare professional: An independent medical
practitioner or another appropriately trained medical worker who is not employed by the
same group practice or who belongs to a different medical specialty or specialization. This
consists of credentialed professionals who are operating their own businesses independently.
It is also possible for the individual to be a facility or organizational providers, such as one
from a hospital, nursing home, or home health care service.
Discussion: Discussion includes both listening to one another and speaking with one
another. The transaction needs to take place directly, without the participation of any
middlemen (e.g., clinical staff or trainees). It is not considered an engaging dialogue to just
send chart notes or have written conversations that are included inside progress notes. The
debate does not always need to occur on the same day as the encounter in order for it to be
counted; nonetheless, it is only counted once and only when it is included in the decision-
making process of the encounter. It is possible for it to be asynchronous, which means that
it does not have to take place in person; nonetheless, it must be started and finished in a
very short amount of time (for example, within a day or two).

- 21 -
Self-governing historian(s): A person (such as a parent, guardian, surrogate, spouse, or
witness) who gives a history in addition to the history given by the patient when the patient
is unable to give a complete or reliable history (for example, because of a developmental
stage, dementia, or psychosis) or when a confirmatory history is thought to be necessary.
The requirement for an independent historian is met when there may be disagreements or
poor communication between more than one historian, and more than one historian is
needed. Translation services are not part of it. The independent history doesn't have to be
gotten in person, but it does have to be gotten directly from the historian who is giving it.
Self-governing analysis: The interpretation of a test that has a CPT code and usually has a
report or interpretation. This doesn't apply if the doctor or other qualified health care worker
who reports the E/M service is also reporting the test or has already done so. A form of
interpretation should be written down, but it doesn't have to meet the usual standards for a
full test report.
Appropriate source: For the purpose of talking about the management data element (see
Table 1, Levels of Medical Decision Making), a lawyer, parole officer, case manager, or
teacher who may be involved in the care of the patient is an example of an appropriate
source. It doesn't include talking with family or other people who help out.
Patient Management Associated Risk of
Complications, Morbidity, and/or Death
The likelihood of complications, morbidity, or death as a result of patient treatment during
an encounter is one consideration that goes into determining the degree of service provided.
This is a separate concern from the possibility of developing the disorder itself.
➢ Risk: It may be defined as the possibility of something happening or its potential
repercussions. The type of occurrence that is being contemplated has a role in the
calculation of the appropriate amount of risk to assign. For instance, a high
probability of a mild, self-limiting adverse impact of therapy may be considered to
have a low risk, whereas a low probability of mortality may be seen to have a high
risk. The actions and ways of thinking that are customary for a physician or another
trained healthcare professional working in the same field serves as the foundation for
risk definitions. It is not necessary for trained doctors to require quantification in
order to apply common language use meanings to terminology such as high, medium,
low, or minimum risk; nonetheless, quantification may be offered when evidence-
based medicine has established probability. In the context of MDM, the level of risk
is determined by the repercussions of the problem (or problems) that were addressed

- 22 -
during the encounter and were successfully resolved. MDM is also a risk factor, and
it is associated with the necessity of beginning additional testing, treatment, or
hospitalization or forgoing these options. The patient management choices that were
part of the reported encounter and were subject to the risk of patient management
criteria include those that were made by the reporting physician or another competent
healthcare provider.
Morbidity is defined as a condition of disease or functional impairment that is
anticipated to last for a significant amount of time, during which function is limited,
quality of life is diminished, or there is organ damage that may not be reversible in
spite of therapy.
Determinants of health that are social in nature: Conditions of economic and social
inequality that have an influence on the physical well-being of individuals as well as entire
communities. Instability about one's access to food or shelter is two such examples.
In the case of surgery (whether small or large, elective or emergency, procedure or
patient risk), the following applies:
Surgical Procedures: Minor or Major: The decision on whether a surgery is considered
minor or major is based on the usual meaning of such terms when used by educated doctors.
This is analogous to how the term "risk" is employed. A categorization for surgical
packages does not provide definitions for these concepts.
Surgical Procedures: Elective or in Case of Emergency: Elective procedures and emergent
or urgent operations explain the time of a procedure when the timing is connected to the
state of the patient. Surgical procedures can be either elective or emergent. An elective
surgery is often one that is planned in advance (for example, it may be scheduled for a few
weeks later), whereas an emergency procedure is typically one that is conducted either
immediately or with little delay in order to allow for patient stabilization. Procedures that
are elective or emergent can both be modest or substantial, depending on their complexity.
Surgical Procedures—Risk Factors Relating to the Patient or the Procedure: The patient
and the operation both have a role in determining which risk factors are significant. In the
process of risk assessment for both the patient and the operation, the use of evidence-based
risk calculators is optional but not obligatory.
"Chemical treatments that require careful supervision because of the risk for toxicity.” A
therapeutic agent that has the potential to cause major morbidity or mortality is referred to
as a drug that requires intensive monitoring because of its potential for toxicity. The
monitoring is carried out, not mainly for the purpose of evaluation, but rather for assessment
of these undesirable impacts.

- 23 -
The surveillance should conform to what is considered standard practice for the drug being
monitored, although in certain instances, it may be tailored to the individual patient. The
duration of intensive monitoring might be either short or long-term. Long-term intense
monitoring is never carried out less frequently than once every three months. The
monitoring might be accomplished through the use of imaging, physiologic testing, or
laboratory analysis. Monitoring via history or examination does not qualify as appropriate
monitoring. During an encounter in which it is taken into consideration for the care of the
patient, the monitoring has an effect on the degree of MDM. For instance, while treating
cancer with an anticancer drug, it is important to check for cytopenia in between dose
cycles. Monitoring glucose levels during insulin therapy is an example of monitoring that
does not qualify because the primary reason for doing so is the therapeutic effect (unless
severe hypoglycemia is a current and significant concern). Another example of monitoring
that does not qualify is annual electrolytes and renal function for a patient who is taking a
diuretic because the frequency does not meet the threshold.
Instructions for Choosing the Appropriate Level
of Service in Conformity with Time
In the E/M section, certain categories of time-based E/M codes that do not have tiers of
services based on MDM (for example, Critical Care Services) employ time in a different
way. It is really necessary to go back and look at the instructions for each category.
Because emergency department services are typically delivered on a variable intensity basis,
frequently involving multiple encounters with several patients throughout a protracted
length of time, time is not a component that is used to describe the levels of emergency
medical the range of services that may be obtained at an emergency department.
When reporting E/M service codes using time, the time that is specified in the service
descriptors is the time that is utilized to determine the appropriate level of service. The E/M
services that fall under the purview of these recommendations need an in-person
consultation between the patient and either the treating physician or another certified
medical practitioner, as well as the patient's family or caretaker. When billing for services
provided in an office or other outpatient setting, use the 99211 code if the total amount of
time that is spent on the medical professional or another qualified health care professional is
spent supervising clinical personnel who are responsible for providing face-to-face services
throughout the encounter.
The entire amount of time spent performing these services should be recorded as the time
component when the encounter was coded. It considers both the time spent with the patient
face-to-face and/or family/caregiver as well as the time spent by the parties involved on the
day of the encounter physician and/or any other competent health care professional(s) that

- 24 -
did not involve face-to-face interaction with the patient. (it considers the time spent on
actions that must be performed by a doctor or another competent health care professional,
but do not take into consideration the patient's time constraints. This, however, doesn't take
into account the amount of time spent on activities that are typically performed by clinical
staff). It considers the time spent with the patient regardless of where the physician or other
competent healthcare practitioner is located (e.g., whether on or off the inpatient unit or in
or out of the outpatient office). It does not account for any of the time spent in the delivery
of a different service that has been independently documented (s).
A shared visit, also known as a split visit, is one that is described as one in which a
physician and/or another certified healthcare professional (s) both provide the face-to-face
and non-face-to-face work that is relevant to the visit. This type of visit is also known as a
split visit. When the length of time is used to choose the right level of service that permits
time-based reporting of shared or split visits are allowed, the total time is defined as the
time personally spent by the physician, and any the patient is also being evaluated and
managed by other certified health care professionals. And/or counseling, educating, as well
as the patient, their family, or the caregiver being informed of the results on the date of the
encounter. During this time, you may carry out any one of the following actions: This is
done when time is used to choose the right Service level at which time-based reporting of
joint or multiple visits is permitted. In other words, this step is taken when time is being
used to choose the right level of service.
When calculating the total amount of time spent on a shared or split visit, only the time
spent on a single visit should be added together. This means that when two or more people
jointly meet with or discuss a patient, only one person's time should be included. When a
considerable period of time passes, the relevant code for prolonged services may be
reported. The length of time spent caring for the patient on the encounter date should be
included in the medical record when it serves as the foundation for code selection. The
following tasks are included in a doctor's or other qualified healthcare professional's time
when they are carried out:
• obtaining the necessary preparations to see the patient (e.g., review of tests)
• gathering and/or examining history that has been gathered independently
• carrying out an examination and/or evaluation that is suitable from a medical
standpoint
• Providing counseling and education to the patient, their family, and/or their
caregivers

- 25 -
• placing an order for medicine, diagnostic testing, or surgical procedures
• sending patients to other healthcare experts and communicating with them (where
this information is not independently recorded).
• recording patient information in an electronic or another type of health record;
independently analyzing outcomes (which are not separately documented) and
conveying results to the patient, family, or caregiver; care coordination (not
separately reported)
Do not count the following activities:
• the efficiency of several other services, which is detailed in separate reports
• travel
• instruction that is comprehensive and does not confine itself just to the conversation
that is necessary for the management
with reference to a particular patient
Service Not Listed
It is possible to deliver an E/M service that is not included in the CPT codebook's
corresponding entry for that area. When reporting such a service, the relevant unlisted code
can be used to denote the service, and it can be identified as a "Special Report," as will be
covered in the paragraph that follows this one. The following is a list of the "Unlisted
Services" that are associated with the E/M section's accompanying codes:
99429 A preventative medicine service that is not mentioned
Evaluation and management service not included under 99499.
Special Report
If the service is not on the list or if it is rare, changeable, or brand new, a separate report
showing the service's appropriateness from a medical standpoint may be required. The
relevant information has to contain a sufficient definition or description of the procedure's
type, extent, and requirement, as well as the amount of time, effort, and equipment required
to offer the service. The intricacy of the symptoms, the definitive diagnosis, important
physical findings, diagnostic and therapeutic treatments, concurrent issues, and follow-up
care may also be included as additional components.

- 26 -
Evaluation as well as
Administration
Office and Other Outpatient Care
Observational Services at a Health Care
Facility
Services for Observational Care and Discharge
➢ (99217 is no longer in use. See 99238, 99239) for information on
reporting observation care discharge services.
Initial Care for Observation
New or Existing Patient
(99217 is no longer in use. See 99238, 99239) for information on reporting
observation care discharge services.
Follow-up Care and Observation
►(99224, 99225, 99226 have now been removed. To record further observation
care, please refer to 99231, 99232, and 99233)
➢ Inpatient Care and Observation
Care Services in a Hospital
➢ The first and subsequent assessment and management services offered to hospital
inpatients and patients designated as hospital outpatients in "observation status" are
reported using the following codes. In addition, codes for hospital inpatient treatment
or observation care are utilized in the reporting of partial hospitalization services.

- 27 -
When a patient is identified or admitted to a hospital with the status of "observation
status," it is not required that the patient be situated in an observation area that is
specifically defined by the hospital. These codes may be used if the patient is moved
to a particular section of the hospital that meets the criteria for this type of location
(for example, a separate unit inside the hospital, the emergency department, or
another similar area). Report codes 99234, 99235, or 99236 depending on whether
the subject was an inpatient or an observer when they were admitted to the hospital
and when they were dismissed from the facility.
The total amount of time on the day of the encounter is based on the calendar date. When
using MDM or total time as a criterion for code selection, a continuous service that covers
the transition between two calendar days is considered a single service and is reported on a
single calendar date. All of the time may be applied to the reported date of the service if it is
determined that the service was continuous before and through midnight.
Inpatient or Observation Care During the Initial
Hospitalization
When reporting a patient's initial interaction with a hospital, whether as an inpatient or in
observation status, the following codes should be used.
During the course of the patient's stay, unless the patient has previously obtained
professional assistance from the doctor or any other qualified health care professional, or
from another physician or any fellow competent medical practitioner working in the same
medical field, with the same expertise and subspecialty, who participates in the activities of
the same group also, an initial service may be reported. An initial service may also be
notified an initial service may also be informed whenever the patient has not obtained any
professional services from any other competent healthcare care provider. This is another
circumstance in which an initial service may be reported. any other qualified healthcare care
professional. An initial service may also be reported when the patient has received
professional services from a physician or other qualified healthcare professional who is not
affiliated with the same group practice. When advanced-practice nurses and physician
assistants work alongside physicians, it is generally understood that they are contributing to
the exact same field of specialization and subfield of specialization as the physician. Please
read 99477 for information on admission services for neonates who have not yet reached 28
days of age and who require intensive surveillance, frequent interventions, and other
intensive care treatments.

- 28 -
➢ When a patient is admitted to a hospital as an inpatient or for observation during a
visit to another site of service (like an emergency room, office, or nursing home), the
services at the first site can be reported separately. A significant, separately
identifiable service that was performed on the same date by the same physician or
some other qualified healthcare professional may be indicated by adding modifier 25
to the other evaluation and management service. This may be done to indicate that
the service was performed on the same date.
If the services at a separate site are being reported, and the initial inpatient or
observation care service is a consultation service, then you should not record 99221,
99222, 99252, 99253, 99254, or 99255. Instead, report the services at the other site.
The subsequent hospital inpatient or observation care codes 99231, 99232, and
99233 are reported by the consultant for the second service on the same day.
If a consultation is performed in anticipation of, or in relation to, an admission by another
physician or other qualified health care professional, and then the same consultant performs
an encounter once the patient is admitted by the other physician or other qualified health
care professional, report the consultant's inpatient encounter with the appropriate subsequent
care code (99231, 99232, 99233). In this scenario, the consultation is considered to be
subsequent care. This instruction is applicable in either the case where the consultation took
place on the same day as the admission or on a date earlier than the admission. Additionally,
it applies to consultations that were reported using any code that was suitable (e.g., office or
other outpatient visit or office or other outpatient consultation).
Report codes 99234, 99235, and 99236 as applicable for a patient who was admitted to and
released from an inpatient or observation status at the same hospital on the same day.
A change from observation level to inpatient status does not constitute a new stay for the
purposes of reporting a first hospital inpatient or observation care service.
 99221 Introductory hospital inpatient or observation care, per day, for the
assessment and treatment of a patient, which needs a medically adequate history
and/or examination and straightforward or low-level medical decision-making. This
type of care is provided in a hospital setting. For the purpose of selecting a code
based on the total duration on the day of the encounter, the threshold of 40 minutes
must be reached or surpassed.
 99222 Initial hospital inpatient or observation care, per day, for the assessment
and treatment of a patient, which needs a medically adequate history and/or
examination and a moderate level of medical decision-making. This type of care may
be provided in a hospital or an observation unit. If the entire duration on the day of

- 29 -
the encounter is being used as a criterion for code selection, 55 minutes must be
fulfilled or surpassed.
 99223 Initial hospital inpatient or observation care, per day, for the assessment
and treatment of a patient that needs a medically adequate history and/or examination
and a high degree of medical decision-making. If the entire duration on the day of
the encounter is being used as a criterion for code selection, 75 minutes must be
reached or surpassed.
► (Use the code 993X0 for prolonged services if your service is at least 90 minutes
long.)
Inpatient or Observation Services at a
Subsequent Date
★▲99231 Care provided in a hospital as an inpatient or under observation, daily, for
the assessment and treatment of a patient, which involves a medically adequate
history and/or examination and a simple or low degree of medical decision-making.
This type of care is provided in hospitals.
To figure out the right code, the whole day of the encounter must last at least 25
minutes, and ideally, it should last longer.
99232 Subsequent hospital inpatient or observation care, per day, for the evaluation
and care of a patient, who needs an adequate medical history and/or examination and
a moderate level of medical decision-making. This care is given to people who must
remain in the hospital for a minimum of one day.
In order to determine the appropriate code, the entire duration of the encounter on the
day of the encounter must be at least 35 minutes long and preferably longer.
★▲99233 Subsequent hospital inpatient or observation care, on a per-day basis, for
the purpose of evaluating and managing a patient, wherein it is necessary to conduct
a medically adequate history and/or examination and a high degree of medical
decision-making
When utilizing total time on the day of the encounter for code selection, 50 minutes
must be reached or surpassed.
(For operations extending 65 minutes or more, use the extended services code
993X0.)
Services Relating to Hospitalization,
whether as an Inpatient or Observer (This
Includes Both Admission and Discharge)
➢ Reporting hospital inpatient or observation care services rendered to patients
who were admitted and released on the same date of treatment requires the

- 30 -
use of the following codes. Refer to codes 99221, 99222, 99223, 99231,
99232, 99233, 99238, and 99239 for information on individuals who were
admitted to a hospital as inpatients or for observation care but were
discharged on a separate date. The requirements for the codes 99234, 99235,
and 99236 are that there must be two or more interactions on the same day,
with at least one of these encounters being a discharge experience and the
other encounters being initial admission encounters. Refer to codes 99221,
99222, and 99223 for information on a patient who was admitted and
discharged within the same encounter (also known as "one encounter"). When
you are reporting admission and discharge services that were completed on
the same day, do not record 99238, 99239 in combination with 99221, 99222,
or 99223. (The code 99463 should be used for discharge services provided to
babies who were hospitalized and discharged on the same date.)
➢ 99234 Hospital inpatient or observation care for the management and
evaluation of a patient who is recently admitted and released on the same day
and who requires a medically necessary history and/or exam as well as
straightforward or low-level medical judgments. Care like this is also called
observation care.
For code selection, the total time on the day of the encounter must be at least
45 minutes, but it must be longer than that.
➢ 99235 Hospital inpatient or observation care for a patient who needs a
medically adequate history and/or exam and a moderate level of medical
decision-making. This includes admitting and releasing the patient on the
same day.
To find the right code, the whole day of the encounter must last at least 70
➢ 99236 Hospital inpatient or observation care for a patient who needs a
medically adequate history and/or exam and a lot of medical decisions to be
made, including admission and discharge on the same day.
To find the right code, the whole day of the encounter must last at least 85
(Use prolonged services code 993X0 for services lasting 100 minutes or
more.)

- 31 -
Services for hospital inpatients or
observation discharge
If a physician or other qualified health care professional spends any amount of time on the
date of the encounter preparing a patient for final hospital or observation discharge,
regardless of whether that time was spent in a single block or in multiple blocks, the time
should be reported using the hospital inpatient or observation discharge day management
codes. These codes are to be used for reporting the total amount of time a physician or other
qualified healthcare professional spent on the day of the encounter managing the discharge
of a hospital inpatient or observation patient.
The codes encompass the last evaluation of the patient, a discussion of the patient's stay in
the hospital, instructions for the continuation of treatment to be given to all necessary
caregivers, and the compilation of discharge records, prescriptions, and referral forms.
Whenever a patient's date of discharge from inpatient or observation status differs from the
date of admission, these codes should be used to accurately record all care provided to the
patient on the day of release. Patients who were either admitted as inpatients or as
observation patients on the day of their discharge should be reported using either code
99234, 99235, or 99236.
Only the attending physician or another qualified healthcare professional in charge of
discharging a patient should use the 99238 and 99239 codes. Instructions to the patient
and/or family/caregiver and coordination of post-discharge services provided by other
physicians or certified health care professionals may be recorded using 99231, 99232, or
99233. More than 30 minutes on the day of the encounter 99238 Management of hospital
inpatients or patients under observation who are being discharged on the same day 99239
(For hospital inpatient or observation care including the admission) 99240 Patient or
observer in a medical facility
Consultations
When another doctor, nurse, or other competent medical professional asks for advice on
how to treat a patient's condition, they are asking for a consultation, which is an
examination and management service. It is customary for the asking doctor to cover the cost
of the consultation.
An appointment with a doctor or other qualified healthcare expert may involve only a
consultation at this time, or it may lead to the beginning of treatment and/or diagnostic
procedures at a later date.

- 32 -
Patient and family-initiated "consultations" that were not sought by a physician or other
qualified health care provider or another acceptable source should not be reported using
consultation codes (such as a non-clinical social worker, educator, lawyer, or insurance
company). A documented report outlining the consultant's assessment and any subsequent
recommendations or treatment must be sent to the requesting physician and any other
relevant healthcare professionals or sources. If a consultation is needed (for example, by a
third-party payer), it should be known that modifier 32 is being used.
➢ When a patient is accepted as an inpatient or for observation, or when they are moved
to a different unit, the hospital must be told so that they can bill for their services. In
a nursing home, throughout the course of contact in another environment, please refer
to First Hospital Inpatient or Initial Nursing Home Care or Observation.
Consultations Conducted Outside of a
Healthcare Facility
Consultations given outside of a hospital setting, such as in a patient's home, place of
business, or emergency room, can be reported using the following codes. Appropriate codes
for established patients visiting the office (99212, 99213, 99214, 99215) or home or
residence (99216) for follow-up appointments are recorded whether the appointment is
started by the consultant or the patient (99347, 99348, 99349, 99350). New or established
patient codes are recorded for office or other outpatient visits or home or resident services
that represent a transfer of care (i.e., are given for the management of the patient's overall
care or for the care of a specific ailment or issue).
➢ (Use for outpatient consultations that require extended service times.
99417). (99242 is now the reporting number; 99241 has been removed)
 99242 Consultation at a doctor's office or another outpatient setting for a new or
established patient that necessitates a brief medical history, a physical exam, and
some basic medical judgment. Codes can only be chosen if the entire duration on the
day of the encounter is greater than 20 minutes.
 99243 Consultation with a new or established patient in an office setting or another
outpatient setting that necessitates a medically adequate history and/or examination
but only minimal medical decision-making. Codes can only be chosen if the entire
duration on the day of the encounter is greater than 30 minutes.
 99244. Consultation with a new or existing patient in an office setting or another
outpatient setting requires a medically adequate history and/or examination and some

- 33 -
independent medical judgment. Codes can only be chosen if the entire duration on
the day of the encounter is greater than 40 minutes.
 99245 Consultation with a new or current patient in an office or other outpatient
setting requiring a comprehensive medical history, physical examination, and/or
advanced medical decision-making.
When choosing a code based on the overall amount of time spent on the day of the
meeting, 55 minutes must be reached or surpassed.
(Prolonged services code 99417 should be used for visits that last 70 minutes or
more.)
Consultations for Inpatient or
Observation
The codes 99252, 99253, 99254, and 99255 are used to record physician or other qualified
healthcare professional consultations given to hospital inpatients, observation-level patients,
nursing home residents, or patients in a partial hospital setting when the patient hasn't had
any face-to-face medical care from the doctor, another qualified healthcare provider, or
another doctor, another qualified healthcare provider of Advanced practice nurses and
physician assistants are seen as practicing in the same specialties and subspecialties as
doctors when they collaborate with them. A consultant may only report one consultation per
admission. For more consultation services during the same hospital stay (99307–99310), use
the following inpatient or observation hospital care codes (99231–99233) or the following
nursing home care codes. (Use 993X0 for an inpatient observation or consultation that takes
a long time; 99251 has been taken away.) Use 99252 to report.
 99252 Inpatient or observation consultation for a new or existing patient
requiring an uncomplicated medical assessment and/or history and/or
examination. 35 minutes must be reached or surpassed when choosing a code
using the total time on the encounter date.
 99253 Inpatient or observation consultation for a new or existing patient
requiring a low degree of medical decision-making and a medically adequate
history and/or examination. 45 minutes must be fulfilled or surpassed when
choosing a code using the total time on the encounter date.
 99254 Inpatient or observation consultation for a new or existing patient,
requiring a moderate level of medical decision-making and a medically
adequate history and/or examination. When choosing a code, the entire
duration on the encounter date must be at least 60 minutes long.

- 34 -
 99255 For a new or existing patient, an inpatient or observation consultation
is necessary, along with a thorough medical history, examination, and
decision-making. 80 minutes must pass on the encounter date in order to use
the entire time for code selection. (Use the prolonged services code 993X0 for
services lasting 95 minutes or more.)
Services for Medical Emergencies
The assessment and management services offered in the emergency room are reported using
the following codes. In the emergency room, there is no distinction between new and
returning patients. A structured hospital-based facility for the provision of unplanned
episodic services to patients who appear to need immediate medical assistance is referred to
as an "emergency department." The facility must be open every day of the week.
See the Critical Care guidelines and the numbers 99291, and 99292 for information on
critical care services offered in the emergency room. When the patient's health worsens
following emergency department treatment and critical care services are given, both
emergency department and critical care services may be recorded on the same day.
See 99221, 99222, 99223 for the initial observation encounter and 99231, 99232, 99233,
99238, 99239 for subsequent or discharge hospital inpatient or observation visits for
assessment and management services provided to a patient in observation status. See 99234,
99235, or 99236 for services related to a hospital inpatient or observation care, including
admission and discharge services.
See Initial Hospital Inpatient or Observation Care or Initial Nursing Facility Care to record
services when a patient is admitted to a hospital inpatient or observation status or to a
nursing facility during an interaction in another location.
Use the relevant CPT code for operations or services designated by a CPT code that can be
independently reported on the same day. Report independently identifiable assessment and
management services as well as the scope of services included in a surgical package using
the applicable modifier(s).
Use office or other outpatient service codes if a patient is seen in the emergency room at the
request of a doctor or other competent health care provider (99202-99215).
Considerations Regarding Time in the Context of an Emergency Department

- 35 -
Because emergency department services are often offered on a variable intensity basis,
frequently requiring many interactions with several patients over a lengthy period of time,
time is not a descriptive factor for the emergency department levels of E/M services.
Guidelines for Choosing the Level of Service Based on Time, CPT Coding Guidelines,
Evaluation, and Management
 99281 Visit to an emergency department for the purpose of diagnosis and treatment
of a patient who might not need the presence of a doctor or some other certified
medical professional in the health care industry
of a patient, which calls for history and/or examination that is medically suitable and
uncomplicated processes for making medical decisions
of a patient, which calls for history and/or examination that is medically suitable and
a poor degree of decision-making in medical matters
 99284 A visit to the emergency room for the purpose of examination and care of a
patient, which calls for history and/or examination that is medically suitable and a
considerable amount of decision-making in medical matters
 99285 Visit to an emergency department for the purpose of examination and care of a
patient, which calls for a history and/or examination that is medically suitable and an
advanced degree of clinical decision-making
Patients in the Emergency Department Can Be Classified as Either New or
Established.
In the emergency department, there is no differentiation made between new patients
and those who have already been seen. Any new or established patient who presents
themselves for treatment in the emergency department is eligible to have their E/M
services reported as part of the emergency department category.
Evaluation and management, classification of emergency and medical services, new
and established patients, and the CPT Coding Guidelines.

- 36 -
Different Kinds of Emergency
Services
When providing directed emergency treatment or advanced life support, a doctor or
other certified healthcare provider is present in the emergency or critical care area of
a hospital and converses with ambulance or rescue workers outside the facility via
two-way voice communication. For example, telemetry of cardiac rhythm, cardiac
and/or pulmonary resuscitation, endotracheal or esophageal obturator airway
intubation, intravenous fluid administration, intramuscular, intratracheal, or
subcutaneous drug administration, and/or electrical conversion of arrhythmia are all
examples of necessary medical procedures that need to be directed.
Emergency care and advanced life support are directed by a doctor or other
competent health care professional in 99288.
Services for Nursing Facilities
The evaluation and management services provided to patients in nursing homes
and skilled nursing institutions are reported using the following codes. A patient
receiving evaluation and management services in a mental health residential
treatment facility or an urgent care facility for people with intellectual
impairments should also be reported using these codes.
The kind and minimum frequency of evaluations and visits are governed by
regulations relevant to the care of nursing facility patients. These rules also
specify who is authorized to conduct the first comprehensive visit.
The primary physician(s) and any other licensed healthcare provider(s) in charge
of the patient's care at the facility provide these services. The primary physician,
also known as the admitting physician, is the medical practitioner who is in
charge of the patient's treatment as opposed to other doctors or other trained
healthcare workers who could be providing specialty care. In the capacity of a
specialist providing consultation or contemporaneous care, doctors or other
trained healthcare providers can also provide these services. It could be necessary
to use modifiers to specify which individual is providing the service.
Care received at a nursing home for the first time, and care received at a nursing
home afterward are the two main subcategories of nursing facility services that
are recognized. Both divisions are applicable to both new and current patients.

- 37 -
The same codes are used to report all care kinds, such as skilled nursing facilities
and nursing facility care. To identify the kind of institution (and level of care)
where the service(s) are provided, the place of service codes should be recorded.
The quantity and complexity of the issues raised during the encounter are
considered when deciding on the degree of medical decision-making (MDM) for
nursing facility services. A high-level MDM-type unique to first nursing facility
care provided by the primary physician or another qualified healthcare
practitioner is acknowledged for this judgment. This kind is
the need for rigorous management due to many morbidities: a group of ailments,
syndromes, or functional impairments that may call for frequent drug
adjustments, as well as additional therapy adjustments and/or reevaluations. The
patient faces a serious risk of deteriorating medical (and behavioral) conditions as
well as the danger of hospital (re)admission.
The criteria for how much data must be evaluated and processed, how
complicated it must be, and how likely it is that patient treatment may result in
problems, morbidity, or mortality remain the same.
Initial Care inside a Nursing
Facility
➢ When a patient is taken to a nursing home during the course of an interaction at
another site of treatment (for example, the emergency department of a hospital or an
office), the services provided at the initial site may be recorded separately. A
significant, separately identifiable service that was performed on the same date by
the same physician or some other qualified healthcare professional may be indicated
by adding modifier 25 to the other evaluation and management service. This may be
done to indicate that the service was performed on the same date.
Do not report 99252, 99253, 99254, 99255, 99304, 99305, or 99306 when services at
a separate site are being reported, and the initial nursing facility care service was a
consultation service performed by the same physician or other qualified healthcare
professional and reported on the same date. In this scenario, the nursing facility care
service was performed on the same date. For the second service on the same day, the
consultant records the subsequent nursing facility care codes 99307, 99308, 99309,
and 99310.

- 38 -
Initial nursing facility care codes (99304, 99305, 99306) as well as inpatient or observation
consultation codes may be used to indicate initial services provided by other physicians and
other competent healthcare professionals who are providing consultations (99252, 99253,
99254, 99255). The principle care expert does not need to finish the initial comprehensive
services before doing this.
When a patient has not previously received any face-to-face professional services from the
doctor, another qualified healthcare provider, or another doctor or other qualified healthcare
provider of the exact same specialty and subspecialty who is a member of the same group
practice during their stay, an initial service may be reported. When working alongside
physicians, advanced practice nurses and physician assistants are regarded as practicing in
the same specialty and specialization as the physician. If the patient is a new patient as
described in the Evaluation and Management Guidelines, an initial service may also be
documented.
Transitions from skilled nursing facility level of care to nursing facility level of care do not
count as a new stay for reporting first nursing facility care.
 99304 Initial nursing facility care, per day, for the assessment and treatment of a
patient, which needs a medically adequate history and/or examination and a
straightforward or low degree of medical decision-making. This care must be
provided in a nursing facility. In order to determine the appropriate code, the entire
duration on the day of the encounter must be at least 25 minutes long, and ideally, it
should be longer.
 99305 Initial nursing facility care, on a per-day basis, for the assessment and
management of a patient, which needs a medically adequate history and/or
examination and a moderate level of medical decision-making. This type of care is
provided in a nursing facility. In order to determine the appropriate code, the entire
duration on the day of the encounter must be at least 35 minutes long and preferably
longer.
 99306 Initial nursing facility care on a per-day basis for a patient who requires a
medically acceptable history and/or examination as well as a high degree of medical
decision-making in order to be evaluated and managed. For the purpose of code
selection, the entire duration on the day of the encounter must be at least 45 minutes
long, and it must be longer than that.
► (Use the prolonged services code 993X0 for any service that is 60 minutes or longer.)

Evaluation and Management EM of the CPT Codes (PDF)

Evaluation and Management EM of the CPT Codes (PDF)

Recommended

Recommended

More Related Content

Similar to Evaluation and Management EM of the CPT Codes (PDF)

Similar to Evaluation and Management EM of the CPT Codes (PDF) (20)

Recently uploaded

Recently uploaded (20)

Evaluation and Management EM of the CPT Codes (PDF)