CPT Evaluation and Management Coding
What this domain tests
Office and outpatient E/M items test the 2021 guidelines: level by medical decision making (MDM) or total time on the encounter date, not a combination. New patients use 99202–99205; established patients use 99211–99215.
Core rules
- MDM has three elements: number and complexity of problems, amount/complexity of data, and risk. Two of three must meet a level.
- Moderate risk includes prescription drug management; low risk includes over-the-counter drugs and minor surgery without risk factors.
- Time is total time on the date, including pre- and post-encounter work, and must be documented. 99214 is 30–39 minutes; 99215 is 40–54 minutes.
- 99211 requires no MDM or time and is for services of a nurse or other staff under physician supervision.
- New versus established depends on whether the patient received a professional service from the group within three years.
Worked example
An established patient has hypertension and GERD, both stable, and the physician renews lisinopril and omeprazole after reviewing labs. Problems: two or more stable chronic illnesses, moderate. Data: review of labs, limited. Risk: prescription drug management, moderate. Two of three elements are moderate, so report 99214. If the visit lasted 34 minutes and was documented, time would also support 99214.
Traps
Adding time and MDM; counting time for 99211; using history or exam to set the level; billing new patient when seen within three years; counting time outside the encounter date; ignoring split/shared rules.