How E/M coding works

What E/M codes are

E/M services are the visits in which a physician or other qualified health care professional evaluates a patient and manages their care. For office and outpatient visits, CPT® provides two code families: 99202–99205 for new patients and 99212–99215 for established patients. Code 99201 was deleted on January 1, 2021. Code 99211 remains for established-patient visits that may not require the physician's presence and carries no medical decision making or time requirement.¹

The 2021 change: decision making or time

Effective January 1, 2021, the American Medical Association and CMS revised the office and outpatient E/M guidelines. The level of a visit is selected by one of two paths: the level of medical decision making (MDM), or the total time the physician or qualified health care professional spent on the date of the encounter. A history and physical examination are still performed and documented as medically appropriate, but their extent no longer determines the code.^{1, 6}

In 2023 the same framework was extended to most other E/M categories, including hospital inpatient and observation, emergency department, nursing facility, and home visits; emergency department visits are leveled by MDM only.^{2, 3}

Medical decision making

MDM is rated straightforward, low, moderate, or high across three elements: the number and complexity of problems addressed at the encounter; the amount and/or complexity of data to be reviewed and analyzed; and the risk of complications and/or morbidity or mortality of patient management. To report a given level, two of the three elements must meet or exceed that level.¹

The table below summarizes what each level looks like in the AMA's Table 2. The problems column lists the qualifying problem types; the risk column gives the AMA's examples. The data element has its own category rules, listed in the source.¹

Total time on the date of the encounter

When a visit is leveled by time, all of the practitioner's time on the date of the encounter counts, face-to-face and non-face-to-face: preparing to see the patient, reviewing history, performing the medically appropriate examination, counseling and educating the patient or family, ordering medications, tests, or procedures, communicating with other professionals, documenting in the record, independently interpreting results, and coordinating care, provided the activity is not separately reported. Travel and general teaching that is not specific to the patient do not count.¹

Each code carries a minimum total time. The 2021 code set published these as ranges (for example, 30–39 minutes for 99214); the current CPT® code set is the authority for the exact time descriptors. The table lists each code with its MDM level and minimum time side by side.

When a time-based visit runs past the highest-level code, CPT® code 99417 is reported for each additional 15 minutes beyond 99205 or 99215. Medicare uses HCPCS code G2212 instead, counted beyond the maximum time of the primary code; under CMS guidance, 99215 with one unit of G2212 covers 69–83 minutes.^{1, 3}

The Medicare add-on G2211

Since January 1, 2024, Medicare pays the add-on code G2211 with an office or outpatient E/M visit when the practitioner is the continuing focal point for all of the patient's needed services or is providing ongoing care for a single serious or complex condition. It does not change the E/M level itself.^{5, 3}

Why E/M levels get audited

In a nationwide review of 2010 claims published in 2014, the HHS Office of Inspector General found that 42 percent of Medicare E/M claims were incorrectly coded and 19 percent lacked documentation, amounting to $6.7 billion in improper payments.⁷

E/M levels are a recurring audit target because level selection is a judgment applied to documentation. The OIG's earlier trend analysis found physicians shifting toward higher-level codes between 2001 and 2010, with about 1,700 physicians consistently billing the highest levels in 2010.⁸ This is why the level, the MDM elements or time that support it, and the note passages behind them need to be traceable for every visit. That traceability is what the MedChartScan E/M audit produces.

Sources

1. CPT® Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services code and guideline changes, effective January 1, 2021 (opens in a new tab) — American Medical Association (with March 9, 2021 technical corrections)
2. CPT® Evaluation and Management overview (opens in a new tab) — American Medical Association
3. Evaluation and Management Services (MLN006764), May 2026 revision (opens in a new tab) — Centers for Medicare & Medicaid Services
4. Evaluation and Management Visits resource page, including the E/M, split/shared visit, and G2211 FAQs (opens in a new tab) — Centers for Medicare & Medicaid Services
5. Calendar Year 2024 Medicare Physician Fee Schedule final rule fact sheet (November 2, 2023) (opens in a new tab) — Centers for Medicare & Medicaid Services
6. CY 2021 Physician Fee Schedule final rule, 85 FR 84472 (December 28, 2020) (opens in a new tab) — Federal Register
7. Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010 (OEI-04-10-00181), May 2014 (opens in a new tab) — HHS Office of Inspector General
8. Coding Trends of Medicare Evaluation and Management Services (OEI-04-10-00180), May 2012 (opens in a new tab) — HHS Office of Inspector General

Questions