Access the below E/M related information from this page.

• 2021 Office/Outpatient Guidelines
• 1995 and 1997 Guidelines
• Chronic Care Management (CCM)
• Critical Care Services
• Evaluation and Management Clarification
• Home and Domiciliary Visits
• Medical Necessity
• New Patient vs Established Patient Visits
• Non-Physician Practitioner in Multi-specialty Group
• Observation and Inpatient (E/M) Common Denials and Resolutions
• Prolonged Service Code
• Related Latest Updates Articles
• Resources
• Transitional Care Management (TCM)
• Unlisted E/M Service CPT Code 99499 - Initial Hospital Care after Observation

Evaluation and Management codes are determined based on the documentation provided by the author of the medical record. The 1995 and 1997 guidelines counted items a provider documented. The 2021 guidelines capture the providers thought process to develop treatment for the beneficiary, and do not count bullets.

2021 Office/Outpatient Guidelines

Effective January 1, 2021, Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) revised office and outpatient E/M guidelines for CPT codes 99202-99205 and 99211-99215. Providers billing for these services will have the choice to document office/outpatient E/M visits via medical decision making (MDM) or total time.

• Changes include deletion of CPT code 99201
• Guideline changes are specific for office and other outpatient visits and apply only to codes 99202-99205 and 99211-99215
• Providers may choose E/M visit level based on either medical decision making or total time
  • May determine most advantageous level on an encounter to encounter basis
• The 1995 and 1997 E/M guidelines will no longer be used for office/outpatient E/M visits for dates of service on and after January 1, 2021

Time

• Total time includes both face-to-face and non-face-to-face spent relative to the beneficiaries care on the actual date of the encounter
  • Time spent separately by clinical staff is not included in calculating time
  • Reviewing medical history, test results, or other sources on another date will not count towards total time on the date of the encounter
• Share or split visit when a physician and other qualified healthcare professional jointly provide face-to-face and non-face-to-face work related to the visit
  • Only distinct time (time of one professional) can be counted when meeting jointly with the beneficiary or to discuss treatment. Double counting minutes is not allowed
• Physician/other qualified health care professional time includes the following activities when performed:
  • Preparing to see the patient (eg, review of tests)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate examination and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, tests, or procedures
  • Referring and communicating with other health care professionals (when not separately reported)
  • Documenting clinical information in the electronic or other health record
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • Care coordination (not separately reported)

Medical Decision Making (MDM)

• Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Medical decision making in the office and other outpatient services code set is defined by three elements. Level of MDM is based on meeting two out of three elements:
  1. The number and complexity of problem(s) that are addressed during the encounter
  2. The amount and/or complexity of data to be reviewed and analyzed. This data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter.
     • Includes information obtained from multiple sources or interprofessional communications that are not separately reported
     • Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter
     • The actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when reported separately. If it is billed separately, cannot receive credit for order and interpretation in the MDM. (see below in services reported separately)
     • Data is divided into three categories:
       • Tests, documents, orders, or independent historian(s). (Each unique test, order, or document is counted to meet a threshold number)
       • Independent interpretation of tests
       • Discussion of management or test interpretation with external physician, other qualified healthcare professional, or appropriate source
  3. The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient's problem(s), the diagnostic procedure(s), treatment (s).
     • This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family
• Four types of MDM levels - straightforward, low, moderate and high
• Definitions for elements of MDM (defined by AMA)
  1. Problem: A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter
  2. Problem addressed: A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in the patient's medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being 'addressed' or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service
  3. Minimal problem: A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician's or other qualified health care professional's supervision (see 99211)
  4. Self-limited or minor problem: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status
  5. Stable, chronic illness: A problem with an expected duration of at least a year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). 'Stable' for the purposes of categorizing medical decision making is defined by the specific treatment goals for an individual patient. A patient that is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant. Examples may include well-controlled hypertension, non-insulin dependent diabetes, cataract, or benign prostatic hyperplasia
  6. Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor, but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain
  7. Chronic illness with exacerbation, progression, or side effects of treatment: A chronic illness that is acutely worsening, poorly controlled or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects, but that does not require consideration of hospital level of care
  8. Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast
  9. Acute illness with systemic symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms such as fever, body aches or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness or to prevent complications, see the definitions for 'self-limited or minor' or 'acute, uncomplicated.' Systemic symptoms may not be general but may be single system. Examples may include pyelonephritis, pneumonitis, or colitis
  10. Acute complicated injury: An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity. An example may be a head injury with brief loss of consciousness
  11. Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care
  12. Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, or an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Examples may include acute myocardial infarction, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, or an abrupt change in neurologic status
  13. Test: Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test. The differentiation between single or multiple unique tests is defined in accordance with the CPT code set
  14. External: External records, communications and/or test results are from an external physician, other qualified health care professional, facility or healthcare organization
  15. External physician or other qualified healthcare professional: An external physician or other qualified health care professional is an individual who is not in the same group practice or is a different specialty or subspecialty. It includes licensed professionals that are practicing independently. It may also be a facility or organizational provider such as a hospital, nursing facility, or home health care agency
  16. Independent historian(s): An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian(s) is needed, the independent historian(s) requirement is met
  17. Independent Interpretation: The interpretation of a test for which there is a CPT code and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional is reporting the service or has previously reported the service for the patient. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test
  18. Appropriate source: For the purpose of the Discussion of Management data element, an appropriate source includes professionals who are not health care professionals, but may be involved in the management of the patient (eg, lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers
  19. Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as 'high', 'medium', 'low', or 'minimal' risk and do not require quantification for these definitions, (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization
  20. Morbidity: A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment
  21. Social determinants of health: Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity
  22. Drug therapy requiring intensive monitoring for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent but may be patient specific in some cases. Intensive monitoring may be long-term or short term. Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Examples may include monitoring for a cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis. Examples of monitoring that does not qualify include monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern); or annual electrolytes and renal function for a patient on a diuretic as the frequency does not meet the threshold

Services Reported Separately

• Any specifically identifiable procedure or service (ie, identified with a specific CPT code) performed on the date of E/M services may be reported separately
• The actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when reported separately. If it is billed separately, cannot receive credit for order and interpretation in the MDM
• Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code
• The physician's interpretation of the results of diagnostic tests/ studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended
• If a test/study is independently interpreted in order to manage the patient as part of the E/M service, but is not separately reported, it is part of medical decision making

For further guidance, see AMA E/M office visit revisions and the AMA Table: CPT E/M Office Revisions - Medical Decision Making (MDM).

1995 and 1997 Guidelines

1995 Guidelines: Medicare Physician Guide: 1995 Guidelines (cms.gov)

1997 Guidelines: Medicare Physician Guide: 1997 Guidelines (cms.gov)

Medical Necessity

The following is an excerpt from the CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1,

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported."

Furthermore, all services must be sufficiently documented so the medical necessity is clearly evident. Medicare cannot pay for services for which the documentation does not establish the medical necessity. Section 1862(a)(1)(A) of Title XVIII of the Social Security Act provides "no payment may be made under Part A or B (of Medicare) for any expense incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".

Services rendered should be billed to Medicare based on the medical necessity of the visit. If the visit does not necessitate the detail of documentation required to meet CPT code 99XXX a lower level of service should be billed. Do not include additional components in the record for the sole purpose of meeting a specific CPT code.

Medical necessity cannot be quantified using a points system. Determining the medically necessary level of service (LOS) involves many factors and is not the same from patient to patient and day to day. Medical necessity is determined through a culmination of vital factors, including, but not limited to:

• Clinical judgment
• Standards of practice
• Why the patient needs to be seen (chief complaint)
• Any acute exacerbations/onsets of medical conditions or injuries
• The stability/acuity of the patient
• Multiple medical co-morbidities
• And the management of the patient for that specific DOS

Other publications to assist with coding and determining the level of service are

• Current Procedural Terminology® (CPT)
• National Correct Coding Initiative (NCCI)

While the publications listed above are available for documentation and/or coding assistance, they are strictly guidelines, and do not provide a definitive answer to determine the level of service for E/M claims.

The coding of services submitted to Medicare is ultimately the responsibility of the service provider. Regardless of a separate entity coding and/or submitting the claims, the provider who rendered the services is held accountable for the level of service billed.

The medical necessity of laboratory tests and/or radiological testing needs to be clearly stated in the medical record. Noridian has found the medical record fails to establish the medical necessity of a lab order. Without the rationale clearly indicated in the medical record, the service becomes not medically reasonable and necessary, and thus denied.

Resources

• American Medical Association (AMA) Current Procedural Terminology® (CPT) Revisions - 2021
• AMA Table: CPT E/M Office Revisions - Medical Decision Making (MDM)
• CMS Fact Sheet January 11, 2021 Physician Fee Schedule (PFS) Payment for Office/Outpatient Evaluation and Management (E/M) Visits - Fact Sheet (cms.gov)
• CMS Fact Sheet: Finalized Policy, Payment and Quality Provision Changes to Medicare Physician Fee Schedule for CY 2020
• CMS MM12071 Summary of Policies in the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
• CMS Final Rule Fact Sheet Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021
• CMS Evaluation & Management Visits | CMS
• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Physicians/Nonphysician Practitioners
• CMS Change Request (CR)7405 - Clarification of Evaluation and Management (E/M) Payment Policy
• CMS Medicare Learning Network (MLN) Matters (MM)6698 - Signature Guidelines for Medical Review