office visit cpt code time

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Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

All specific references to CPT codes and descriptions are © 2023 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Download the Office E/M Coding Changes Guide (PDF)

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Evaluation and management (E/M) services are an essential part of medical practices, especially in family medicine. These services are categorized using Current Procedural Terminology (CPT) codes for billing purposes. Properly documenting and coding for E/M services is crucial to maximize payment and minimize audit-related stress.

There are different levels of E/M codes, determined by the medical decision-making or time involved. It’s worth noting that the guidelines for E/M coding have undergone changes, including the elimination of history and physical exam elements, revisions to the MDM table, and an expanded definition of time for E/M services.

Key Takeaways:

• Understanding E/M codes and guidelines is crucial for accurate billing.
• There are different levels of E/M codes based on medical decision-making or time involved.
• Recent changes to E/M coding include the elimination of history and physical exam elements.
• The definition of time for E/M services has been expanded.
• Proper documentation and coding help maximize payment and reduce audit-related stress.

Overview of Office Visit CPT Code Changes

The CPT Editorial Panel made significant revisions to the documentation and coding guidelines for office visit E/M services in 2021, with further changes introduced in 2023. These updates aim to simplify documentation requirements, reduce administrative burden, and ensure accurate coding for evaluation and management services.

One of the key changes introduced is the addition of add-on code G2211. This code accounts for the resource costs associated with visit complexity inherent to primary care and other longitudinal care settings. The inclusion of this add-on code reflects a more comprehensive understanding of the unique challenges and workload associated with these types of visits.

Additionally, the revisions eliminate the requirement for history and physical exam elements to be considered in E/M code level selection. This change allows healthcare providers to focus more on medical decision-making (MDM) and limits the need for extensive documentation of these elements in the medical record.

The MDM table has also been revised to better reflect the cognitive work required for evaluation and management services. This ensures that the complexity of the MDM is accurately captured in the coding process and supports appropriate reimbursement for the level of care provided.

Furthermore, the definition of time for many E/M services has been expanded. The expanded definition of time includes both face-to-face and non-face-to-face components of care on the day of the encounter. This change recognizes the comprehensive nature of care provided and allows for a more accurate reflection of the time spent in the management of the patient.

Using Total Time for Office Visit CPT Code Selection

When it comes to selecting the appropriate office visit CPT code, total time can be a valuable factor to consider. Total time refers to the sum of all the physician’s or qualified health professional’s (QHP) time spent in caring for the patient, both face-to-face and non-face-to-face, on the day of the encounter. This expanded definition of time allows for a more comprehensive evaluation and management of the patient’s needs.

Total time can be utilized in selecting the level of service for various evaluation and management services, including office visits, inpatient and observation care, consultations, nursing facility services, home and residence services, and prolonged services. It provides a broader perspective on the physician’s involvement in the patient’s care, taking into account all aspects of their interaction.

However, it’s important to note that for emergency department visits, the level of service is still determined primarily by medical decision-making (MDM), rather than total time. This distinction recognizes the critical nature of emergency care and the need for prompt assessment and action.

Accurate documentation of the total time spent is key to ensuring proper code selection and appropriate reimbursement. The total time should be well-documented in the patient’s medical record, including both the face-to-face and non-face-to-face components of the encounter. This documentation serves as a crucial reference point for billing and auditing purposes.

To summarize, total time offers a comprehensive perspective on the physician’s engagement with the patient, encompassing both face-to-face and non-face-to-face interactions. It allows for a more accurate selection of office visit CPT codes and ensures the appropriate level of reimbursement for the provided services. Proper documentation of total time is essential to support the medical necessity of the encounter and maintain compliance with coding and billing guidelines.

Documentation Requirements for Total Time Calculation

When determining the total time for selecting office visit CPT codes, it is essential to adhere to specific documentation requirements. By accurately documenting the time spent on various activities during the encounter, healthcare providers can ensure proper code selection and optimize reimbursement.

To calculate the total time for office visit code selection, the following activities should be included:

• Reviewing external notes/tests
• Performing an examination
• Counseling and educating the patient
• Documenting in the medical record

These activities reflect the time personally spent by the physician or qualified health professional (QHP) on the date of the encounter. However, there are also activities that should be excluded when calculating total time:

• Time spent on activities typically performed by ancillary staff
• Time related to separately reportable activities

It is crucial to specifically document the total time spent on each activity during the date of the encounter, rather than providing generic time ranges. This detailed documentation ensures transparency and accuracy in code selection and reimbursement.

In addition to capturing face-to-face time, it is important to record non-face-to-face time as well. Non-face-to-face time includes tasks performed outside of direct interaction with the patient, such as reviewing test results or consulting with other healthcare professionals.

Example of Total Time Calculation:

Let’s consider an example where a family physician spends the following time on a patient encounter:

• 45 minutes performing an examination and counseling
• 15 minutes reviewing external notes/tests
• 10 minutes documenting in the medical record
• 5 minutes discussing with an ancillary staff

In this case, the total time would be calculated as follows:

By accurately documenting the specific total time spent on each activity and excluding ancillary staff time, healthcare providers can ensure proper code selection and reimbursement. This meticulous documentation of total time in the medical record provides a comprehensive overview of the services rendered and supports accurate billing.

Split or Shared Visit Documentation Guidelines

A split or shared visit occurs when a physician and other qualified health professional (QHP) provide care to a patient together during a single Evaluation and Management (E/M) service. In such cases, the time personally spent by the physician and QHP on the date of the encounter should be summed to define the total time.

However, only distinct time should be counted. This means that overlapping time during jointly meeting with or discussing the patient should not be double-counted. The distinct time should represent the unique contribution of each provider involved in the split or shared visit.

It is important to note that time spent on activities performed by ancillary staff should not be included in the total time calculations. The total time should only reflect the face-to-face time and distinct time spent by the physician and other QHP directly involved in providing the medically necessary services.

Documentation should support the medical necessity of both services reported in a split or shared visit scenario. This includes clearly documenting the need for both physicians or QHPs to be involved and the services each provider contributed to the patient’s care.

Applying Total Time to Specific E/M Services

Total time is a valuable tool for selecting the appropriate level of service for a variety of Evaluation and Management (E/M) services. This method can be applied to different specific E/M services, ensuring that the level of care is clinically appropriate and adequately reimbursed. By considering the total time spent during the encounter, healthcare providers can accurately assign the appropriate office visit CPT code.

The application of total time is not limited to office visit services. It can also be used for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services. This flexibility allows for a comprehensive approach to E/M coding, regardless of the specific type of service provided.

When selecting the visit level based on total time, it is important to ensure that the encounter is counseling-dominated. While total time can be used as the sole determinant for selecting the visit level, counseling should still play a significant role in the encounter. This ensures that the level of service reflects the complexity and intensity of the counseling provided during the visit.

It is crucial to emphasize that total time should be clinically appropriate and supported by documentation in the medical record. This documentation should clearly demonstrate the medical necessity of the services provided and the time spent on the date of the encounter.

Applying Total Time to E/M Services: An Example

To illustrate the application of total time to specific E/M services, let’s consider an example of an office visit for a counseling-dominated encounter:

In this example, the total time spent during the encounter determines the appropriate level of visit code. For a total time of 25 minutes, a level 3 visit (CPT code 99213) is selected. If the total time is 40 minutes, a level 4 visit (CPT code 99214) would be appropriate. Finally, a total time of 60 minutes would result in a level 5 visit (CPT code 99215).

By applying total time to specific E/M services, healthcare providers can ensure accurate coding and appropriate reimbursement for the care provided. This method promotes comprehensive and patient-centered care while maintaining compliance with coding guidelines. Understanding the nuances of applying total time is essential for optimizing billing practices and promoting quality healthcare delivery.

Caveats and Considerations for Time-based E/M Coding

When utilizing time as the basis for selecting E/M codes, there are important caveats and considerations to keep in mind. Time-based coding should only be used in situations where counseling dominates the encounter, and it should not include time spent on separately reportable services. Documentation should clearly indicate that the services provided were not duplicative and were necessary for the management of the patient. Additionally, it is crucial to note that the professional component of diagnostic tests/studies and activities performed on a separate date should not be included in the total time calculation.

Considerations for Time-based E/M Coding

• Use time-based coding only when counseling dominates the encounter.
• Exclude time spent on separately reportable services.
• Ensure documentation supports the necessity of the provided services.
• Do not include the professional component of diagnostic tests/studies.

Implications of Time-based E/M Coding

When selecting E/M codes based on time, it is important to adhere to the specified guidelines and considerations. Failing to do so can lead to inaccurate coding, reimbursement issues, and potential compliance concerns. By understanding the requirements and accurately documenting the relevant information, healthcare providers can ensure proper medical billing and maintain compliance with coding and documentation guidelines.

Documentation Requirements for Time-based E/M Coding

Updates and Changes to CPT E/M Guidelines

The CPT Editorial Panel has recently implemented updates and changes to the Evaluation and Management (E/M) guidelines, specifically focusing on medical decision making (MDM), history, and exam. These updates aim to enhance the accuracy and specificity of E/M coding and documentation.

One significant change in the new guidelines is the emphasis on a medically appropriate history or exam, rather than relying solely on the number or complexity of problems addressed. This shift highlights the importance of gathering comprehensive patient information to guide medical decision making.

The MDM levels have also been revised to align with those used for office visits. This alignment ensures consistency across different types of E/M services and facilitates accurate code selection for medical billing and reimbursement.

By updating and refining the guidelines, the CPT Editorial Panel aims to streamline the coding and documentation process, making it easier for healthcare providers to accurately capture the complexity of patient encounters and facilitate proper reimbursement.

Changes in CPT E/M Guidelines

| Old Guidelines | Updated Guidelines | |—————————-|———————————| | Emphasized number of | Emphasize medically appropriate | | problems addressed | history or exam | | MDM levels differed across | MDM levels align with office | | different E/M services | visit levels | | | |

The updates in the CPT E/M guidelines bring about significant changes in capturing the complexity of patient encounters. Healthcare providers should familiarize themselves with these updates to ensure compliance with the revised guidelines, thereby facilitating accurate coding, billing, and reimbursement.

Guidelines for MDM Selection in E/M Services

In the process of selecting the appropriate E/M codes for evaluation and management (E/M) services, medical decision making (MDM) plays a crucial role. MDM encompasses several factors that need to be considered, including the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

It is important to note that the final diagnosis alone does not determine the complexity of MDM. Rather, the complexity is determined by the impact of the condition on the management of the patient. The more complex the problems, comorbidities, and data analysis, as well as the higher the risk of complications, morbidity, or mortality, the more intricate the MDM.

In accurately reflecting the level of complexity in the documentation and coding of E/M services, healthcare providers ensure proper reimbursement and compliance with coding guidelines. By carefully evaluating the factors that contribute to MDM, providers can effectively demonstrate the complexity of the problems addressed and the resources required to manage them.

Here is a breakdown of the key considerations for MDM selection in E/M services:

• Number and complexity of problems addressed
• Comorbidities
• Amount and complexity of data reviewed and analyzed
• Risk of complications, morbidity, or mortality
• Final diagnosis and its impact on management
• Complexity of problems and their management

Accurately documenting and coding the appropriate level of MDM is essential for ensuring proper reimbursement and comprehensive representation of the complexity of the patient’s condition. It is crucial to pay attention to the specifics of each patient’s case and make informed decisions based on thorough evaluation and analysis.

Impact of Office Visit CPT Code Changes on Medical Billing

The changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. Healthcare providers must adapt to these changes and understand the documentation requirements and accurate coding necessary to ensure proper reimbursement and reduce the risk of audits.

Accurate coding is crucial in accurately reflecting the level of service provided during the office visit. It ensures that healthcare providers receive accurate reimbursement for their services and helps to reduce the burden of potential audits. Proper documentation and coding also contribute to compliance with coding and documentation requirements, mitigating the risk of financial loss and noncompliance.

It is essential for healthcare providers to familiarize themselves with the new guidelines and understand how to properly document the relevant information. This includes accurately capturing the level of service provided, the complexity of problems addressed, and the time spent on the date of the encounter. By adhering to these documentation requirements, healthcare providers can ensure accurate coding and reimbursement, reducing the risk of claims denials or audits.

Proper documentation not only helps in accurate coding and reimbursement but also simplifies auditing processes, ensuring compliance with coding and documentation requirements. Auditing plays a vital role in the healthcare system, and having the appropriate documentation in place can streamline the auditing process and provide evidence of accurate and compliant billing practices.

Compliance with coding and documentation requirements is essential to avoid potential financial loss and maintain a good standing within the healthcare industry. By accurately documenting and coding office visit services, healthcare providers can demonstrate their commitment to compliance and ensure that they are providing high-quality care to their patients.

In conclusion, the changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. It is crucial for healthcare providers to understand the documentation requirements, accurately code the services provided, and ensure compliance with coding and documentation guidelines. By doing so, healthcare providers can streamline the billing process, reduce the risk of audits, and ensure accurate reimbursement for their services.

Resources for Understanding Office Visit CPT Code Guidelines

When it comes to understanding the guidelines for office visit CPT codes and navigating the changes in E/M coding, healthcare providers can rely on valuable resources provided by reputable organizations such as the American Medical Association (AMA) and the Medicare Learning Network (MLN). These resources offer comprehensive guidance and tools that can help healthcare providers stay up to date and ensure accurate reimbursement.

The CPT Evaluation and Management Services Guidelines, developed by the AMA, provide detailed information on office visit CPT codes, E/M coding principles, and documentation requirements. This resource serves as a comprehensive guide to help healthcare providers understand the intricacies of office visit coding and ensure compliance with the latest guidelines.

The Medicare Learning Network, an educational resource developed by the Centers for Medicare & Medicaid Services (CMS), offers webinars, articles, and other educational materials specifically designed to assist healthcare providers in understanding and implementing the changes in E/M coding. These resources provide practical insights and clarification on the documentation requirements and coding changes specific to office visit CPT codes.

Furthermore, the Medicare Physician Fee Schedule Lookup Tool, available on the CMS website, enables healthcare providers to access reimbursement information for specific office visit CPT codes. This tool allows providers to accurately determine the appropriate reimbursement for their services and ensure proper billing practices.

By leveraging these resources, healthcare providers can enhance their understanding of office visit CPT code guidelines, navigate the complexities of E/M coding, and ensure accurate reimbursement for their services. Staying informed and utilizing these valuable resources is imperative for maintaining compliance and optimizing coding practices.

Understanding the guidelines for office visit CPT codes is essential for accurate medical billing and insurance reimbursement. The recent changes in E/M coding guidelines, particularly regarding time-based code selection and medical decision making, necessitate proper documentation and accurate coding. By comprehensively understanding these guidelines, healthcare providers can maximize their payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

Accurate medical billing is crucial for healthcare practices to receive fair reimbursement from insurance companies. By following the comprehensive guide provided by the American Medical Association (AMA) and the Medicare Learning Network (MLN), healthcare providers can confidently navigate the complexities of office visit CPT codes. This comprehensive guide provides detailed information on selecting the appropriate codes based on medical decision making, time-based code selection, and documentation requirements.

Properly documenting the relevant information and coding accurately not only ensures accurate reimbursement but also reduces the risk of audits and increases compliance. By adhering to the guidelines and best practices outlined in the comprehensive guide, healthcare providers can maintain accurate and compliant medical billing practices, ultimately benefiting both their practice and their patients.

In conclusion, understanding the guidelines for office visit CPT codes is crucial for accurate medical billing and insurance reimbursement. By following the comprehensive guide provided by industry resources such as the AMA and MLN, healthcare providers can navigate the changes in E/M coding and ensure compliance with coding and documentation requirements. This comprehensive understanding of the guidelines allows healthcare providers to optimize payment, minimize audit-related stress, and maintain accurate and compliant medical billing practices.

What are office visit CPT codes?

Office visit CPT codes are evaluation and management (E/M) codes used for billing purposes in family medicine practices and other healthcare settings.

What are the changes to the office visit CPT code guidelines?

The office visit CPT code guidelines have been revised to eliminate the history and physical exam elements, introduce an add-on code for visit complexity, revise the medical decision-making table, and expand the definition of time for E/M services.

How can total time be used for office visit CPT code selection?

Total time, which includes both face-to-face and non-face-to-face interactions, can be used to select the level of service for office visit codes and other E/M services.

What should be included in the calculation of total time for office visit code selection?

Activities such as examining the patient, counseling and educating the patient, reviewing external notes/tests, and documenting in the medical record should be included in the calculation of total time. Ancillary staff time and time related to separately reportable activities should be excluded.

How should total time be documented for office visit code selection?

It is important to document the specific total time spent on activities on the date of the encounter in the patient’s medical record, rather than providing generic time ranges.

What are the documentation guidelines for split or shared visits?

In a split or shared visit scenario, the time personally spent by the physician and other qualified health professional (QHP) should be summed to define total time. Distinct time should be counted, and time spent on activities performed by ancillary staff should not be included.

Can total time be used for other E/M services besides office visits?

Yes, total time can be used to select the level of service for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services.

What are the caveats and considerations for time-based E/M coding?

Time-based coding should only be used when counseling dominates the encounter, and it should not include time spent on separately reportable services. It is important to ensure that the services provided were necessary for the management of the patient.

What updates have been made to the CPT E/M guidelines?

The CPT E/M guidelines have been updated to emphasize the need for a medically appropriate history or exam and to revise the levels of medical decision making to align with office visit levels.

How is medical decision making (MDM) determined in E/M services?

MDM is determined by considering the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

What is the impact of the office visit CPT code changes on medical billing?

The changes in office visit CPT code guidelines have a significant impact on medical billing, requiring proper documentation and accurate coding to ensure accurate reimbursement and reduce the risk of audits.

Where can healthcare providers find resources to understand the office visit CPT code guidelines?

Healthcare providers can refer to resources such as the CPT Evaluation and Management Services Guidelines from the American Medical Association and the Medicare Learning Network for guidance on understanding and implementing the office visit CPT code guidelines.

What is the importance of understanding office visit CPT code guidelines?

Understanding office visit CPT code guidelines is crucial for accurate medical billing, insurance reimbursement, and compliance with coding and documentation requirements.

What is the overall purpose of the comprehensive guide on office visit CPT code guidelines?

The comprehensive guide on office visit CPT code guidelines provides healthcare providers with a thorough understanding of the guidelines, enabling them to maximize payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

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List With CPT Codes For New Patient Office Visits | Short & Long Descriptions and Lay-Terms

4 CPT codes describe the procedures for a new patient office visit . These codes are used to record the level of complexity of the evaluation, management, and medical decision-making during the visit. You can find a complete list of office visits for both established patients and new patients here.

1. CPT Code 99202

Lay-term: CPT code 99202 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and straightforward medical decision making. The total time spent on the encounter must be 15 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.

Short description: New patient office visit, straightforward medical decision making, 15 minutes.

1.2. CPT Code 99203

Lay-term: CPT code 99203 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a low level of medical decision making. The total time spent on the encounter must be 30 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.

Short description: New patient office visit, low level medical decision making, 30 minutes.

1.3. CPT Code 99204

Lay-term: CPT code 99204 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a moderate level of medical decision making. The total time spent on the encounter must be 45 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.

Short description: New patient office visit, moderate level medical decision making, 45 minutes.

1.4. CPT Code 99205

Lay-term: CPT code 99205 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a high level of medical decision making. The total time spent on the encounter must be 60 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.

Short description: New patient office visit, high level medical decision making, 60 minutes.

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April 19, 2024

Coding for Prolonged Services: CPT and HCPCS Codes

Common rules:

• Prolonged services codes are add-on codes to E/M services.
• In order to use prolonged care, the primary code must be selected based on time. This is in the CPT and HCPCS definition of prolonged services.
• Prolonged services codes may only be added to the highest-level code in the category.
• The full 15 minutes of prolonged services must be met. These do not follow the CPT mid-point time rule.
• The work of the prolonged care may include both face-to-face and non-face-to-face time.
• Prolonged care services can no longer be used on psychotherapy codes. There is no replacement code.

Where the rules vary:

• There are different CPT® and HCPCS codes that describe the same prolonged care services.
• In the 2024 CPT book, time ranges were removed from the office visit codes, and they now have only a single, threshold time listed. CMS has changed its manual or time thresholds for using prolonged care in response to this.
• For other services (hospital, nursing facility and home and residence services), CPT® uses the times stated in the CPT® book for the primary code when calculating if a prolonged services code may be added. CMS uses the time in the CMS time file , which includes pre and post visit times on other days, to calculate if prolonged care services may be added to hospital, nursing facility and home and residence services.
• CPT® includes only time spent on the date of the encounter. For hospital, nursing facility and home and residence services, CMS uses time on other dates of service.
• CPT® still has non-face-to-face prolonged care in the CPT® book, codes 99358, +99359 which can be used on days that do not include a face-to-face visit. CMS has given them a status indicator of invalid and doesn’t pay for them. There is no replacement of these services for Medicare patients.
• Home and residence services
• Hospital services
• Nursing facility for services
• Table 24 from the Final rule

Implementing prolonged services codes

Coding prolonged services in the office.

CMS does not recognize consultation codes.

Note: For home and residence services and assessment of cognitive functions, see below.

Coding for prolonged services is complicated by the fact CPT ®  and CMS use different codes and different time thresholds. These codes and rules have been in effect since 2021.

• The AMA developed CPT ® code 99417 for 15 minutes of prolonged care, done on the same day as office/outpatient codes 99205 and 99215.
• Medicare has assigned a status indicator of invalid to code 99415, and developed a HCPCS code to replace it, G2212
• If using either code, only report it with codes 99205 and 99215, use only clinician time, and use it only when time is used to select the code
• Use for time spent face-to-face and in non-face-to-face activities

In their 2021 Physician Fee Schedule Final Rule, CMS indicated its agreement with the new E/M definitions for codes 99202-99215 that were developed by the AMA that are in the 2021 CPT ®  book. However, CMS and the AMA  are not in agreement about the use of prolonged care code 99417, resulting in HCPCS code.

Using time for E/M services

A practitioner may include these activities in their time, when using time to select an E/M service:

• 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)

Per CPT, use 99417 for office visits, outpatient consults, home and residence services and cognitive assessment planning.

# ✚  99417  Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)

(Use 99417 in conjunction with 99205, 99215, 99245, 99345, 99350, 99483)

(Use 99417 in conjunction with 99483, when the total time on the date of the encounter exceeds the typical time of 99483 by 15 minutes or more.)

• You can’t report the new add on code on the same day as 90833, 90936, 90838, non-face-to-face prolonged care codes 99358, 99359 or staff prolonged care codes.
• The time reported must be 15 minutes, not 7.5 minutes. The entire 15 minutes must be done, in order to add on this new, prolonged services code.

CMS developed its own code G2212

G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT ® codes 99205, 99215 for office or other outpatient evaluation and management services)

(Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes)).”

Both CMS and CPT allow a prolonged service in addition to 99483, assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home. The typical time for this code is 60, making the threshold time to add a prolonged care code 75 minutes. Note that CMS allows the practitioner to include time spent three days before the date of the visit and seven days after.

Coding prolonged services in a home or residence

For CPT®, use add-on code 99417 for prolonged care. As with all of these codes, both CPT ®️  and HCPCS, the prolonged code may only be added to the highest-level code in the category and then only when time is used to select the service.  The definition of 99417 is above.

G0318  ( Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99345, 99350 for home or residence evaluation and management services). (Do not report G0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417). (Do not report G0318 for any time unit less than 15 minutes) )

CMS is allowing time on days prior to and after the date of the encounter to be used for prolonged services in relation to home/residence visits.

Coding prolonged services in the hospital: CPT and HCPCS codes

99418 Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the inpatient and observation Evaluation and Management service)

(Use in 99418 conjunction with 99223, 99233, 99236, 99255, 99306, 99310) (Do not report 99418 on the same date of service as 90833, 90836, 90838, 99358, 99359) (Do not report 99418 for any time unit less than 15 minutes)

99418 may be used on the highest-level initial and subsequent inpatient and observation codes, inpatient consult, and initial and subsequent nursing facility services. It may not be reported with psychotherapy or non-face to face prolonged care codes, or discharge services 99238, 99239, 99315, 99316. It may not be used with Emergency Department codes. The full 15 minutes is required and time must have been used to select the level of service.

As expected, CMS is not recognizing the new CPT ®  code 99418. For Medicare patients, there is a HCPCS code. CMS is not using the published CPT typical times for the codes, but the time in the CMS time file, developed by the RUC. For Medicare patients, the time thresholds to add G0316 are different than those in our CPT books. CMS is not using allowing practices to report G0316 when the time is 15 more minutes than the CPT ® typical time. Instead, in a break from prior policy, CMS is using the time in the CMS time file. The  2023 time file is here .

G0316 Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT ®  codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). (Do not report G0316 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418). (Do not report G0316 for any time unit less than 15 minutes)

See the CMS Table 24 below. CMS is allowing time on after the date of the encounter to be used for prolonged services in relation to hospital services.

Coding prolonged services in a nursing facility

Prolonged services in a nursing facility: CPT code 99418/HCPCS code for Medicare G0317

CPT ®  defines the new prolonged add-on code 99418 (above) as the code to use in a nursing facility, as well as in the hospital. And, CPT ®️ simply states to use the code when the total time of the highest-level service (selected based on time) is 15 minutes more than the time described in the CPT ®️ book. Both the base time and the prolonged time can include face-to-face care and non-direct care on the date of the visit.

G0317 ( Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99306, 99310 for nursing facility evaluation and management services). (Do not report G0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418,). (Do not report G0317 for any time unit less than 15 minutes) )

Table 24 Required Time Thresholds to Report Other E/M Prolonged Services

* Time must be used to select visit level. Prolonged service time can be reported when furnished on any date within the primary visit’s surveyed timeframe, and includes time with or without direct patient contact by the physician or NPP. Consistent with CPT’s approach, we do not assign a frequency limitation.

The source of this chart is CMS’s 2023 Final Rule. It doesn’t follow CPT typical times, or CPT prolonged services rules. It includes time for some services on the days before or after the face-to-face encounter.  It adds to confusion and complexity for medical practices.

Implementation of using prolonged care HCPCS codes

It was never easy for clinicians to select prolonged services codes. When they were applicable to all levels of service, the threshold time was different for each code. Now, they are only applicable on the highest level of service, but there are two sets of codes and the time thresholds are different for each one. This makes no sense. Effectively, all prolonged services coding will need to be done by coders. Effectively, it is so byzantine that most practices will never be able to bill for them.

Add-on prolonged services HCPCS codes

Can an add-on code to be submitted without its primary code? In particular, the add-on prolonged services HCPCS codes developed by CMS.

An add-on code must be submitted with its primary code. A colleague said she was getting conflicting opinions about this. Let’s see what CPT® and CMS say.

Page xviii of the CPT® Professional Edition 2024  states, “Add-on codes are always performed in addition to the primary service or procedure and must never be reported as a standalone code.” It is easy to ignore the information in the introduction of the CPT® book but when I’m stuck, I regularly find answers there. And wish I had started looking there in the first place!

What about CMS? CMS has edits in place to ensure that an add-on code is only paid when reported with a correct primary code. Naturally, they have three levels of edits but you can read about this on the CMS website .

I think the question was prompted by the fact that for certain services provided by practitioners in a facility the add-on prolonged care codes includes time the days before or in the days after the face-to-face encounter. You can see the chart from the CMS final rule and read about it here .

I don’t know what edits individual MACs are setting up for these codes, but I recommend that you continue to submit all add-on codes on the claim with the primary code, following CPT® rules and CMS guidance.

Non-face-to-face prolonged services codes 99358, 99359

The non-face-to-face prolonged care codes are still active, billable codes. But, they may not be reported on the same date of service as 99202-99215 per CPT®. And, Medicare has given them a status code of invalid, which means they won’t pay for it. And, there is not a replacement code for this service for Medicare.

I understand from your article about prolonged services in 2021 that CMS won’t pay for prolonged code 99417 and instead developed a HCPCS code for the service. (G2212)   Do you have any recommendations about how to manage this in the office?

Although in general, I believe most clinicians can code for most of the work they do (not a universally held opinion, I know) this is a case where the claims must go to a coder for review. Not only are there different codes depending on payer, the time thresholds are different. CPT® allows you to add the 15 minutes to the lower time threshold in the range, and CMS requires you to add the 15 minutes to the higher time threshold in the range.

Just a few reminders. The prolonged codes can only be used on 99205 and 99215, and only when time is used to select the office visit code. The total time must be documented. CMS’s manual does not currently require start and stop times. Look for a description of what activities are included in the time, because this is required when using time to select the office visit codes. “I spent 90 minutes caring for the patient today. It included reviewing test results, documenting in the record and arranging for follow up at pain management. It also included an extensive discussion with the patient and his sister about treatment options and recovery time, if he decides on surgery.”

Source documents

• EM from 2020 Final Rule
• G2212 from 2021 Final Rule

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Last revised April 8, 2024 - Betsy Nicoletti Tags: CPT updates , prolonged care

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Simplified guidelines for coding and documenting evaluation and management office visits are coming next year. Learn how to apply the guidelines to some common visit types.

CAROL SELF, CPPM, CPC, EMT, KENT MOORE, AND SAMUEL L. CHURCH, MD, MPH, CPC, FAAFP

Fam Pract Manag. 2020;27(6):6-11

Author disclosures: no relevant financial affiliations disclosed.

Editor's note: In its 2021 Medicare Physician Fee Schedule, CMS released new guidance regarding coding for prolonged E/M services. This article has been updated accordingly.

The American Medical Association (AMA) has established new coding and documentation guidelines for office visit/outpatient evaluation and management (E/M) services, effective Jan. 1, 2021. The changes are designed to simplify code selection and allow physicians to spend less time documenting and more time caring for patients. Physicians and other qualified health professionals (QHPs) will be able to select the level of office visit using either medical decision making (MDM) alone or total time (excluding staff time) on the date of service. In addition, the history and physical exam will be eliminated as components of code selection, and code 99201 will be deleted (code 99211 will not change). (See “ E/M coding changes summary .”)

To follow up on the previous FPM article detailing these changes (see “ Countdown to the E/M Coding Changes ,” FPM , September/October 2020), we have applied the 2021 guidelines to some common types of family medicine visits, and we explain below how documentation using a typical SOAP (Subjective, Objective, Assessment, and Plan) note can support the chosen level of service.

In each vignette, we've arrived at a code based only on the documentation included in the note. It's possible that a more extensive note could support a higher level of service by further clarifying the physician's decision making. But we've analyzed each case through an auditor's lens and tried not to make any assumptions that aren't explicitly supported by the note.

Starting in January, physicians and other qualified health professionals will be able to select the level of office visit using either medical decision making alone or total time (excluding staff time) on the date of service.

Medical decision making is made up of three factors: problems addressed, data reviewed, and the patient's risk. The highest level reached by at least two out of three determines the overall level of the office visit.

If the visit was time-consuming, but the medical decision making did not rise to a high level, the physician or qualified health professional may want to code based on total time instead.

MEDICAL DECISION MAKING (MDM)

Starting in January, physicians will be able to select the level of visit using only medical decision making, with a revised MDM table. (See the table at https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf .)

The four levels of MDM (straightforward, low, moderate, and high) will be maintained but will no longer be based on checkboxes or bullet points. The level of service will be determined by the number and complexity of problems addressed at the encounter, the amount and complexity of data reviewed and analyzed, and the patient's risk of complications and morbidity or mortality.

Here's what that looks like in practice:

STRAIGHTFORWARD MDM VIGNETTE

An established patient presents for evaluation of eye matting. The documentation is as follows:

Subjective: 16 y/o female presents with a 2-day history of bilateral eye irritation. She denies any fever or sick contacts. She started having a slight runny nose and cough this morning. She thinks the matting is a little better than yesterday. She wears daily disposable contacts but hasn't used them since her eyes have been bothering her. Her younger sibling has had similar symptoms for a few days.

Objective: Temperature 98.8, BP 105/60, P 58.

General: No distress. Does not appear ill.

HEENT: Mild bilateral conjunctival erythema without discharge. No tenderness over eye sockets. EOMI, PERRL.

Neck: No cervical lymph nodes palpated.

Lungs: Clear to auscultation.

Assessment: Viral conjunctivitis.

Plan: Reviewed likely viral nature of symptoms. Supportive and conservative treatment options reviewed, including eye cleaning instructions and contact lens precautions. Call the office if symptoms persist or worsen. Avoid use of contacts until symptoms resolve.

CPT code: 99212.

Explanation: Under the 2021 guidelines, straightforward MDM involves at least two of the following:

Minimal number and complexity of problems addressed at the encounter,

Minimal (in amount and complexity) or no data to be reviewed and analyzed,

Minimal risk of morbidity from additional diagnostic testing or treatment.

This is the lowest level of MDM and the lowest level of service physicians are likely to report if they evaluate the patient themselves (code 99211 will still be available for visits of established patients that may not require the presence of a physician).

In this fairly common scenario, the assessment and plan make it clear that the physician addressed a single, self-limited problem (“minimal” in number and complexity, per the 2021 MDM guidelines) for which no additional data was needed or ordered, and which involved minimal risk of morbidity.

Per the 2021 CPT guidelines, “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.” In this case, there is little risk of morbidity to this patient from the viral infection diagnosed by the physician.

It's possible the physician considered prescribing an antibiotic in this case, but decided against it. Options considered but not selected can be used as an element for “risk of complications,” but they should be appropriate and documented. There is no documentation in this note to indicate the physician made that decision. The documentation provided, therefore, does not support a higher level of service using MDM. But if the physician did make that decision and the ensuing conversation with the patient was time-consuming, the physician always retains the option to choose the level of service based on time instead.

LOW LEVEL OF MDM VIGNETTE

An established patient presents for follow-up for stable fatty liver. The documentation is as follows:

Subjective: 62 y/o female presents for follow-up of nonalcoholic fatty liver. She has no other complaints today and no other chronic conditions. She denies any fever, weight gain, swelling, or skin color changes. She also denies any confusion. She continues to work at her regular job and reports no difficulties there. She denies any unusual bleeding or bruising. Energy is good. Diagnosis was made three years ago, incidentally, on an ultrasound. Condition has been stable since the initial full evaluation.

Objective: BP 124/70, P 76, Temperature 98.7, BMI 26.

General: Well-appearing. Alert and oriented x 3.

Eyes: Sclera nonicteric.

Heart: Regular rate and rhythm; trace pretibial edema.

Abdomen: Soft, nontender, no ascites, liver margin not palpable.

Skin: No bruising.

Labs reviewed and analyzed: CBC normal, CMP with elevated AST (62 IU/ml) and ALT (50 IU/ml), PT/PTT normal.

Last ultrasound was 3 years ago.

Assessment: Nonalcoholic steatohepatitis, stable.

Plan: LFTs continue to be improved since initial diagnosis and 30-pound intentional weight reduction. Continue monitoring appropriate labs at 6-month intervals. Follow up in 6 months, or sooner if swelling, bruising, or confusion. Avoid alcohol. Continue weight maintenance. She is reassured her condition is stable and has no other questions or concerns, especially in light of her prior extensive education on the topic. I am arranging for hepatitis A and B vaccination. Discussed OTC medications, including vitamin E, and for now will avoid them.

CPT code: 99213

Explanation: Under the 2021 guidelines, low-level MDM involves at least two of the following:

Low number and complexity of problems addressed at the encounter,

Limited amount and/or complexity of data to be reviewed and analyzed,

Low risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one stable chronic illness, which is an example of an encounter for problems low in number and complexity. The risk of complications from treatment is also low. The “Objective” section indicates review of three lab tests, which qualifies as a moderate amount and/or complexity of data reviewed and analyzed. However, the level of MDM requires meeting two of the three bullets above, so the overall level remains low for this vignette.

MODERATE LEVEL OF MDM VIGNETTE

An established patient with obesity and diabetes presents with new onset right lower quadrant pain. The documentation is as follows:

Subjective: 42 y/o female presents for evaluation of 2 days of abdominal pain. She has a history of Type 2 diabetes, controlled. Pain is moderate, 6/10 currently, and 10/10 at worst. The pain is intermittent. The pain is located in the back and right lower quadrant, mostly. She denies diarrhea or vomiting but does note some nausea. She denies fever. She denies painful or frequent urination. She is sexually active with her spouse. She has had a hysterectomy due to severe dysfunctional bleeding. She has not tried any medication for relief. No position seems to affect her pain. She has not had symptoms like this before. Home glucose checks have been in the 140s fasting. Her last A1C was 6.9% two months ago. Family history: Sister with a history of kidney stones.

Objective: BP 160/95, P 110, BMI 36.1.

General: Appears to be in mild to moderate pain. Frequently repositioning on exam table.

HEENT: Moist oral mucosa.

Abdomen: Mild right-sided tenderness. No focal or rebound tenderness. Normal bowel sounds. No CVA tenderness. No suprapubic tenderness. No guarding.

UA with microscopy: 3 + blood, no LE, 50–100 RBCs, 5–10 WBCs.

CBC, CMP, CT stone study ordered stat.

Assessment: Abdominal pain – suspect renal stone. Also consider cholecystitis, gastroparesis, gastroenteritis, appendicitis, and early small bowel obstruction.

Diabetes, type 2, controlled.

Obesity – this is a risk factor for gall-bladder problems, but still favor renal stone.

Plan: Ketorolac 60 mg given in office for pain relief. Hydrocodone/APAP prescription for pain relief. Discussed at length suspicion of renal stone. Will plan lab work and pain control and await CT stone study. Urine sent to reference lab for microscopy. Drink plenty of fluids. Urine strainer provided. Call the office if worsening or persistent symptoms. Await labs/CT for next steps of treatment plan. Will follow up with her if urology referral is indicated.

CPT code: 99214

Explanation: Under the 2021 guidelines, moderate level MDM involves at least two of the following:

Moderate number and complexity of problems addressed at the encounter,

Moderate amount and/or complexity of data to be reviewed and analyzed,

Moderate risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one undiagnosed new problem with uncertain prognosis (abdominal pain) and two stable chronic conditions (diabetes and obesity). Either one (the new problem with uncertain prognosis or two stable chronic conditions) meets the definition of a moderate number and complexity of problems under the 2021 MDM guidelines. But they do not meet the threshold of a high number and complexity of problems, even when combined.

The physician reviews or orders a total of four tests, which again exceeds the requirements for a moderate amount and/or complexity of data, but doesn't meet the requirements for the high category.

The prescription drug management is an example of moderate risk of morbidity. One might argue that the risk of morbidity is high because renal failure could result from a major kidney stone obstruction. But even then the overall MDM would still remain moderate, because of the number and complexity of problems addressed and the amount and/or complexity of data involved.

HIGH LEVEL OF MDM VIGNETTE

An established patient with a new lung mass and probable lung cancer presents with a desire to initiate hospice services and forgo curative treatment attempts. The documentation is as follows:

Subjective: 92-year-old male presents for follow-up of hemoptysis, fatigue, and weight loss, along with review of his recent chest CT. He reports moderate mid-back pain, new since last week. Appetite is fair. He denies fever. He continues to have occasional cough with mixed blood in the produced sputum.

Objective: BP 135/80, P 95, Weight down 5 pounds from 2 weeks ago, BMI 18.5, O2 sat 94% on RA.

General: Frail-appearing elderly male. No distress or shortness of breath. Able to speak in full sentences.

HEENT: No palpable lymph nodes.

Lungs: Frequent coughing and diffuse coarse breath sounds.

Heart: Regular rate and rhythm.

Ext: No extremity swelling.

MSK: Moderate tenderness over multiple thoracic vertebrae.

CT shows large right-sided lung mass suspicious for malignancy, along with a moderate left-sided effusion. Lytic lesions seen in T6-8.

Assessment: Lung mass, suspect malignancy with bone metastasis.

Plan: After extensive review of the findings, the patient was informed of the likely poor prognosis of the suspected lung cancer. We reviewed his living will, and he reiterated that he did not desire life-prolonging measures and would prefer to allow the disease to run its natural course. He also declines additional testing for diagnosis/prognosis. A shared decision was made to initiate hospice services. Specifically, we discussed need for oxygen and pain control. He declines pain medications for now, but will let us know. He and his son who was accompanying him voiced agreement and understanding of the plan.

CPT code: 99215

Explanation: Under the 2021 guidelines, high level MDM involves at least two of the following:

High number and complexity of problems addressed at the encounter,

Extensive amount and/or complexity of data to be reviewed and analyzed,

High risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one acute or chronic illness or injury (suspected lung cancer) that poses a threat to life or bodily function. This is an example of a high complexity problem in the 2021 MDM guidelines. The physician reviewed one test (CT), so the amount and/or complexity of data is minimal. A decision not to resuscitate, or to de-escalate care, because of poor prognosis is an example of high risk of morbidity, and the physician has clearly documented that in the plan portion of the note. Consequently, even though the amount and/or complexity of data is minimal, the overall MDM remains high because of the problem addressed and the risk involved.

Under the new guidelines, total time means all time (face-to-face and non-face-to-face) the physician or other QHP personally spends on the visit on the date of service. Examples include time spent reviewing labs or reports, obtaining or reviewing history, ordering tests and medications, and documenting clinical information in the EHR.

The AMA has also created a new add-on code, 99417, for prolonged services. It can be used when the total time exceeds that of a level 5 visit – 99205 or 99215. (See “ Total time plus prolonged services template .”)

TIME-BASED CODING VIGNETTE

An established patient presents with a three-month history of fatigue, weight loss, and intermittent fever, and new diffuse adenopathy and splenomegaly. The documentation is as follows:

Subjective: 30-year-old healthy male with no significant PMH presents with a three-month history of fatigue, weight loss, and intermittent fever. He travels for work and has been evaluated in several urgent care centers and reassured that he likely had a viral syndrome. Fevers have been as high as 101, but usually around 100.5, typically in the afternoons. Testing for flu and acute mono has been negative. He denies high-risk sexual behavior and IV drug use. He denies any sick contacts. He has not had vomiting or diarrhea. He has not had any pain. He denies cough.

Objective: BP 125/80, P 92, BMI 27.4.

General: Well-nourished male, no distress.

HEENT: No abnormal findings.

Lungs: Clear.

Heart: No murmurs. Regular rate and rhythm.

Abdomen: Soft, non-tender, moderate splenomegaly.

Skin: Multiple petechia noted.

Lymph: Multiple cervical, axillary, and inguinal lymph nodes that are enlarged, mobile, and non-tender.

Assessment: Weight loss, lymphadenopathy, and splenomegaly

Plan: Prior to the visit, I spent 15 minutes reviewing the medical records related to his recent symptoms and various urgent care visits. We reviewed the differential at length to include infectious disease and acute myelodysplastic condition. I have ordered stat blood cultures, TB test, EBV titers, echo, and CBC. The pathologist called to report concerning findings on the CBC for likely acute leukemia. I called the patient to inform him of his results and need for additional testing. I also discussed the patient with oncology and arranged a follow-up visit for tomorrow. I spent a total of 92 minutes with record review, exam, and communication with the patient, communication with other providers, and documentation of this encounter.

CPT Codes: 99215 and 99417 x 3.

Explanation: In this instance, the physician has chosen to code based on time rather than MDM. The physician has documented 92 minutes associated with the visit on the date of service, including time not spent with the patient (e.g., time spent talking with the pathologist and time spent in documentation). According to the 2021 CPT code descriptors, 40–54 minutes of total time spent on the date of the encounter represents a 99215 for an established patient.

The 2021 CPT code set also notes that for services of 55 minutes or longer, you should use the prolonged services code, 99417, which can be reported for each 15 minutes beyond the minimum total time of the primary service (99215). The difference between the 92 minutes spent by the physician and the 40-minute minimum for 99215 is 52 minutes. There are three full 15-minute units of 99417 in those 52 minutes, so the physician may report three units of 99417 in addition to 99215. CPT 2021 instructs you to not report 99417 for any time unit less than 15 minutes, so the seven remaining minutes of prolonged service is unreportable.

Note that if this had been a new patient, the physician would only be able to report two units of 99417 in addition to 99205. Though the elements of MDM do not differ between new and established patients, the total time thresholds do. The range for a level 5 new patient is 60–74 minutes.

FINAL THOUGHTS

CPT does not dictate how physicians document their patient encounters. As illustrated above, a standard SOAP note can be used to support levels of MDM (and thus levels of service) under the 2021 guidelines.

Physicians who want to further solidify their documentation in case of an audit may choose to make the elements of MDM more explicit in their documentation. This could be particularly helpful for documenting the level of risk, which is the least clearly defined part of the MDM table and potentially most problematic because of its inherent subjectivity. Stating the level of risk and giving a rationale when possible allows a physician to articulate in the note the qualifying criteria for the submitted code. For example, going back to our vignette of moderate MDM, the physician could note in the chart, “This condition poses a threat to bodily function if not addressed, due to acute kidney injury for an obstructive stone.”

It is also worth noting that much of the note in each case is for purposes other than documenting the level of service. For instance, with history and physical exam no longer required, the subjective and objective portions of the note are recorded primarily for continuity or quality of care rather than to justify the level of service. This provides some administrative simplification. What's in the note will become more about what is needed for medical care and less about payment justification under the new guidelines. That's a plus for primary care.

We hope these examples are helpful as you prepare to implement the 2021 CPT changes. You can also visit https://www.aafp.org/emcoding for more resources and information.

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