Evaluation and Management (E/M) Services
This domain tests level selection for office and outpatient E/M services and the rules for other E/M families. The exam focuses on medical decision making, total time, site of service, and same-day procedure interactions.
Office and outpatient E/M rules
- For 99202-99215, select the level by medical decision making or total time on the date of the encounter, never a mix of both.
- MDM has three elements: number and complexity of problems, amount and complexity of data, and risk. A level requires two of the three elements to be met or exceeded.
- Time thresholds: 99202 is 15-29 minutes; 99203 is 30-44; 99204 is 45-59; 99205 is 60-74; 99212 is 10-19; 99213 is 20-29; 99214 is 30-39; 99215 is 40-54.
- 99211 does not require a physician and has no time or MDM threshold; incident-to rules apply.
- Prolonged services 99417 is reported in 15-minute increments beyond the highest-level threshold for 99205 or 99215.
Other E/M families
- Hospital inpatient initial and subsequent care use 99221-99223 and 99231-99233; site and patient status determine the family.
- Emergency department services use 99281-99285; critical care uses 99291 for the first 30-74 minutes and 99292 for each additional 30 minutes.
- Preventive services use 99381-99397; a problem-oriented visit on the same day requires modifier 25.
- Split or shared visits are billed by the practitioner who performed the substantive portion of the service.
Worked example
An established patient has 42 minutes of total time on the date of the encounter and moderate MDM. The time falls in the 40-54 minute range for 99215, so 99215 is supported even though MDM is level 4. Document the total time and that it was spent on the date of the encounter. If only 32 minutes were spent, 99214 would apply. Do not count separately reported procedures in the time.
Traps
- Using 1995 or 1997 bullet counting for office visits.
- Counting teaching, administrative, or separately billed services in time.
- Reporting 99211 for a nurse visit that does not meet incident-to requirements.
- Missing modifier 25 when a significant, separately identifiable E/M occurs with a procedure.
- Selecting a level by documentation volume rather than MDM or time.