Evaluation and Management Coding
Code office visits under the current rules, which are based on medical decision making or total time rather than the old history-and-exam bullet counts.
By the end of this lesson you can
- Explain what E/M codes describe and why they are high volume
- Select an office visit level using medical decision making
- Select a level using total time on the date of the encounter
- Distinguish new from established patients
Lesson Notes
Read through the key concepts before you try the challenge.
The most-billed codes in outpatient medicine
You code a primary care day at Lakeside Medical Associates.
Twenty-two of the day's twenty-four encounters are office visits. Each needs a level assigned — and the level determines payment, so a practice that systematically codes one level too low leaves substantial revenue uncollected, while one that codes too high is submitting false claims.
Your task: Learn to select an office visit level from what the documentation actually supports.
Evaluation and Management codes describe cognitive work: the assessment, the decision making, the counseling. They are the highest-volume codes in outpatient medicine and the most scrutinized, because level selection has historically been inconsistent.
| Patient type | Codes | Definition |
|---|---|---|
| New patient | 99202-99205 | Has not received professional services from the provider, or another of the same specialty in the same group, within three years |
| Established patient | 99211-99215 | Has received such services within three years |
The three-year rule matters financially: new patient visits pay more, because more work is involved in an initial assessment. It turns on the same specialty and same group practice, not merely the same individual provider — a patient seen by a different physician in your practice's same specialty within three years is established.
| Element | Considers |
|---|---|
| Number and complexity of problems addressed | How many problems, and how serious or unstable |
| Amount and complexity of data reviewed | Tests ordered or reviewed, records obtained, discussion with other providers |
| Risk of complications or morbidity | Risk from the problems, the diagnostic testing, and the treatment chosen |
Two of the three elements must be met or exceeded at a given level to support it. The levels run straightforward, low, moderate, and high, corresponding to codes 99202/99212 through 99205/99215.
Selecting a level two ways
An established patient is seen for two chronic conditions, one uncontrolled. The provider reviews recent labs, adjusts a prescription, and documents 40 minutes total on the date of the encounter.
- 1
Try medical decision making first.
Two chronic conditions with one uncontrolled generally supports moderate complexity on the problems element. Reviewing labs contributes to the data element. Prescription drug management is a recognized moderate-risk item. Two of three at moderate supports 99214.
- 2
Then check total time as an alternative.
Time is the other permitted route, and you may use whichever supports the higher level. Total time includes the provider's non-face-to-face work on that date — reviewing records beforehand, documenting afterwards — not only the time in the room.
- 3
Compare 40 minutes against the time thresholds for established patient visits.
40 minutes falls in the range for 99215 rather than 99214. Here time supports a higher level than medical decision making does, so time is the better basis — provided the total time is actually documented.
- 4
Confirm the documentation states total time explicitly.
This is where time-based selection fails. A note saying '40 minutes spent, including review of labs and counseling on medication changes' supports it. A note with no time statement cannot support time-based selection at all, no matter how long the visit actually took.
Result: 99215, supported by documented total time, with medical decision making independently supporting at least 99214.
Check both routes and use whichever the documentation supports at the higher level. Time-based selection requires the total time to be stated in the note.
A patient last seen by a different physician of the same specialty in your practice two years ago returns. Which code family applies?
Challenge
Apply what you've learned in this lesson.
Practice level selection against real documentation standards. Use the current CPT E/M guidelines.
- Read the E/M guidelines at the front of the CPT Evaluation and Management section. Write down the time thresholds for 99212 through 99215.
- For an established patient with one stable chronic condition, no tests ordered, and no prescription change, determine the supportable level using medical decision making and justify it.
- For the same encounter documented as 30 minutes total time, determine the level using time. Explain which basis you would use and why.
- Write three sentences a provider could add to a note that would support time-based selection, and explain what makes them sufficient.
Finished this lesson?
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