Evaluation and Management (E/M) of the CPT® Codes by Kurt Goodwin

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Evaluation and Management (E/M) of the CPT® Codes

Modifications to the CPT® Code and Guidelines

This document has the following changes to CPT E/M:

as of January 1st, 2023:

• Hospital Inpatient and Observation Care Services codes 99221-99223, 99231-99239, Consultations CPT codes 99242-9945, 99252-99255, Emergency Department Services codes 99281-99285, Nursing Facility Services codes 99304-99310, 99315, 99316, Home or Residence Services codes 99341, 99342, 99344, 99345, 9934799350

• Elimination of Hospital Observation Services Electronic Medical Record (EMR) numbers 99217-99220

• Revision of E/M CPT codes 99221-99223, 99231-99239, and recommendations for Hospital Inpatient and Observation Care Services

• Getting rid of the E/M codes 99241 and 99251 for consultations

• Changes to Consultations E/M codes 99242-99245, 99252-99255, and guidelines

• Changes to the Emergency Department Services E/M codes 99281-99285 and the rules for using them

• The Nursing Facility Services E/M code 99318 will no longer be used

• Changes to the Nursing Facility Services E/M codes 99304–99310, 99315, 99316, and guidelines

• Getting rid of E/M codes 99324-99238, 99334-99337, 99339, and 99340 for 'Domiciliary, Rest Home, Boarding Home, or Custodial Care Services

Removal of E/M code 99343 for Home or Residence Services

• Modification of Home or Residence Operations E/M codes 99341, 99342, 99344, 99345, 99347-99350 and their corresponding instructions

• Prolonged Services E/M codes 99354-99357 are no longer in use.

• Guidelines for Prolonged Services E/M codes 99358, 99359, 99415, and 99416 have been revised.

• Updates to the Prolonged Services E/M code 99417, as well as the corresponding guidelines

• The creation of the Prolonged Services E/M code 993X0 and its corresponding guidelines

The American Medical Association's registered trademark is CPT. American Medical Association. Copyright 2022. Every right is retained. It should be noted that future CPT Editorial Panel (Panel) or Executive Committee actions may have an impact on CPT codes and/or descriptions. As a result, the CPT code set's code numbers and/or descriptor language may alter at the time of release. -

Standards for Evaluating & Managing (E/M) Services

In addition to the material discussed in the Introduction, numerous more things specific to this part are defined or specified in this paragraph.

E/M Guidelines Review

➢ The E/M rules contain elements universal to all E/M categories and sections exclusive to their respective categories. The vast majority of service categories, as well as many of the subcategories, each have their own set of rules or instructions exclusive to that category or subclass. Where they are stated, for example, "Hospital Inpatient and Observation Care," special instructions are supplied before the listing of the individual E/M service codes. It is essential to review the guidelines for each category and subcategory carefully. These recommendations are to be utilized by the reporting physician or any other competent healthcare practitioner to identify the appropriate level of service. These recommendations do not impose any documentation requirements or standards of care. The primary goal of documenting patient care is to assist present and future healthcare team members in providing quality care to patients (s). These guidelines apply to services that require face-to-face encounters between the patient, a family member or caregiver, and an attendant. Regarding cases 99211 and 99281, face-to-face services may be carried out by clinical professionals.)

There are a lot of different code categories to choose from under the Evaluation and Management area (99202-99499). It's possible that each category has its own unique set of criteria or that the codes themselves include particulars. The following types of activities are under the purview of these E/M guidelines:

■ Consultations at Offices and Various Other Outpatient Services

■ Services for Hospital Patients Receiving Inpatient Care as Well as Observation Care

■ Consultations

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■ Services Offered at the Emergency Department

■ Services Provided by Nursing Homes

■ Services for the Home or Private Residence

■ Extended Duration of Service Evaluation and management services can be provided either with or without direct patient contact on the date of the service.

Evaluation and Management (E/M) Service Types and Their Classifications

➢ The evaluation and management component are broken up into several major categories, such as consultations, hospital inpatient or observation care visits, and office visits. The majority of categories can each be further broken down into two or more subcategories of E/M services. For instance, there are two types of office visits: new patient visits and existing patient visits. Additionally, there are two subcategories of hospital inpatient and observation care visits (initial and subsequent). The subcategories of E/M services are then further subdivided into tiers of E/M services, each of which is denoted by a unique code.

➢ The core structure of E/M service coding remains the same, with different levels determined by either the amount of time spent or the amount of medical decision-making (MDM). To begin, there is a listing of a one-of-a-kind code number. Second, the location of the service and/or the kind of service provided (e.g., office or another outpatient visit). Third, the specifics of the service's content are outlined. Fourth, a time limit has been set. (The Guidelines for Selecting Level of Service Based on Time give a comprehensive discussion on time.)

➢ The location of the face-to-face meeting with the patient and/or their family or caregiver determines the sort of service provided as well as the site where the service is provided. For instance, a service that was rendered to a resident of a nursing home who was transported to the office should be documented using an office code or another appropriate outpatient code.

Existing and New Patients

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➢ Skilled professionals are those face-to-face services performed by physicians and other certified health care professionals who may report assessment and management services and are used solely to differentiate between new and established patients. Patients who have not seen a doctor or other qualified healthcare professional within the last three years are considered new patients. This includes patients who have seen other doctors or other qualified healthcare professionals in the same group practice but who are not in the same specialty or subspecialty.

➢ A patient is considered to be an established patient if, within the past three years, they have received professional services from either the doctor or another qualified health care professional or from another doctor or skilled health care a member of the medical community who specializes in the same field and subfields but belongs to a different organization practice. Available now is a decision tree that compares new patients to those who have been seen before.

➢ When a physician or other qualified health care professional is covering for another licensed medical practitioner or different appropriately trained health care experience, the encounter with the patient will be coded in the same way that it would have been coded by the physician or other qualified health care professional who is not available. This applies whether the doctor or another trained healthcare provider is on call for the patient or provides coverage. When working alongside physicians, advanced practice nurses and physician assistants are regarded to be practicing within the same medical specialty and specialty as the supervising physician. This is because of the close collaboration between the three professionals.

In the emergency unit, new patients are handled precisely the same as those who have been there for a while and are considered established patients. E/M services are eligible to be recorded under the emergency department category for any new or established patient who presents themselves for treatment in the emergency department. The New Patients vs. Established Patients Decision Tree is offered as a tool to determine whether or not to record the E/M service performed as an interaction with a new patient.

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Useful Hints for Coding Guidelines for Utilizing the Current Procedural Terminology Codebook

When healthcare staff and physician assistants work with doctors, they are considered to be in the same specialty and subspecialty as the doctors. A "doctor or other skilled medical professional" is a person who has the right credentials in terms of education, training, licensure or regulation (if applicable), and facility privileges (if applicable) and who offers expert advice or help within the limits of his or her practice and independently reports that professional service. "Clinical staff" is not the same as these people. A clinical staff member does their job under the direction of a doctor or other qualified healthcare professional and is permitted to do so by applicable laws, regulations, and the facility's operating policy; helps perform a specific professional service but does not report that service individually. There may be additional restrictions that govern who is allowed to report certain services.

The CPT Codebook contains all relevant information, including the CPT Coding Guidelines, an Introduction, and Instructions for Using the CPT Codebook.

Initiation and Subsequent Provision of Services

➢ There are numerous categories that apply to both newly registered patients and those who are already in the system (e.g., hospital inpatient or observation care). Services are placed into one of these categories depending on whether or not the service in question is intended to serve as the foundation for a succession of further services. Professional services are in-person services provided by medical doctors and other qualified healthcare professionals. These experts may record evaluation and management services in order to differentiate between first and future visits. An initial service is provided to a patient during their hospitalization, observation, or admission and stay in a nursing home if they have not been seen by a doctor or any other competent health care professional or if they have not received any professional services from a health care provider. This can also apply if the patient has not previously received medical or mental health care from a health care provider. From another physician or other competent health care provider who is a part of the same group practice and who practices the exact same specialization and specialty as the original patient.

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➢ If a patient has previously received professional services from a physician or another qualified healthcare provider, then this is a subsequent service.

➢ If a physician or other qualified health care professional is covering for another physician or other skilled health care professional, the encounter with the patient will be categorized in the same way that it would have been classified by the physician or other competent health care professional is not available. When advanced practice nurses and physician assistants work alongside physicians, it is generally accepted that they are doing duties associated with the same medical specialization and specialty as the supervising physician.

➢ A hospital stay that involves a transfer from observation to inpatient status is considered a single visit for the purposes of reporting hospital inpatient or observation care services. In the context of the reporting of services provided by nursing facilities, a stay that involves transition(s) between the levels of care provided by a skilled nursing facility and nursing facilities is considered to be the same stay.

Separate Reports on Services

Any method or service that can be identified by a specific CPT code and was done on the same date as E/M services can be reported separately.

• The procedure of assessing the levels of E/M services does not consider situations in which the professional interpretation of diagnostic tests and research is reported independently by the physician or another qualified health care professional who is reporting the E/M service. The reason for this is that ordering, actual performance, and/or interpretation of diagnostic tests and studies conducted during contact with a patient are not regarded to be part of the E/M service. Tests that are evaluated as part of MDM but do not need a distinct interpretation (for example, tests that result only) do not count as an independent interpretation. Instead, these tests might be regarded as ordered or reviewed for the purpose of calculating an MDM level. In addition to the code that corresponds to the appropriate evaluation and management service, it is possible to individually report the results of diagnostic tests and studies for which unique CPT codes are provided. These results can be reported alongside the code that corresponds to the appropriate evaluation and management service. It is possible to report separately both the interpretation of the results of diagnostic tests or studies

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(i.e., the professional component) and the preparation of a separate distinctly identifiable signed written report by making use of the appropriate CPT code and, if necessary, by appending modifier 26 to the end of the code. This would be done in order to receive separate payments for both of these services. This is done in this manner to ensure that we are in accordance with the Medicare rules.

On the day of a treatment or service described by a CPT code, the physician or other qualified healthcare care professional may be required to certify that the patient's condition demanded a significant, independently identifiable E/M service. The symptoms for which the operation and/or service was performed may have prompted or inspired the E/M service. This situation can be indicated by adding modifier 25 to the relevant level of E/M service. Therefore, separate diagnoses are not required when surgery and E/M services are reported on the same day.

The History and maybe the Examination

➢ Levels of services for E/M codes that specify a medically necessary history and/or physical examination. The reporting physician or other competent healthcare practitioner determines the kind and depth of the patient's history and/or physical examination service. A physician or other competent health care professional may evaluate information collected by the care team and information provided directly by the patient or caregiver (through an EHR portal or questionnaire, for example). These E/M service code selections have little to do with the depth of the patient's history and physical exam.

The Different Levels of E/M Services

Determine the right amount of E/M services to provide depending on the factors listed below:

1. The level of the MDM according to its definition for each service, or

2. The cumulative amount of time spent on E/M services that were carried out on the day of the encounter.

There are anywhere from three to five levels of available E/M services for reporting reasons, and these levels may be found under each category or subcategory of E/M service depending on MDM or time. There is no consistent equivalence between the various categories and subcategories of service with regard to the E/M service levels. Take, for instance, the very first.

The first level of E/M services in the office visit subcategory for new patients does not have the same precise definition as the first level of E/M services in the office

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visit subcategory for established patients. Every level of E/M services is available to qualify medical doctors and other professionals working in the healthcare industry.

Medical Decision-Making Guidelines for Service-Level Selection

➢ MDM may be broken down into the following categories:

• straightforward,

• low,

• moderate

• high.

In the cases of 99211 and 99281, the MDM level as a conceptual framework is not applicable.

➢ Establishing diagnoses, determining the current state of a problem, and/or deciding which treatment approach to take are all components of MDM. Three components make up MDM's definition. The following are the components: The number and level of difficulty of the problem(s) that are solved during the course of the encounter.

➢ The volume of data to be examined and/or the level of complexity of the data to be evaluated. These data may consist of a patient's medical records, test results, or other information that has to be gathered, ordered, reviewed, and evaluated prior to the interaction. This comprises information acquired from a variety of sources, as well as interprofessional communications or interpretation of tests that are not recorded individually. The act of ordering a test is considered to be part of the category of test result(s), and the examination of the test result is considered to be an integral aspect of the encounter rather than a separate encounter that comes later. When placing an order for a test, you might add options that were evaluated but ultimately rejected after being shared decision-making. For example, a patient may ask for medical testing that's not required for their situation. In this instance, it may be required to talk about the lack of benefits. And a test may usually be done, but because it could be risky for a certain patient, it is not ordered. These things must be written down. The data are split into three groups:

➢ Tests, papers, instructions, or independent historian (s). (Each test, order, or document is counted separately to reach a certain number.)

➢ Tests that are interpreted on their own (not separately reported).

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➢ Talking with an outside doctor, other qualified health care professional, or appropriate source about how to treat or interpret a test (not separately reported).

➢ The risk of complications, illness, or death from how the patient is cared for. This includes decisions made about the diagnostic procedure(s) and treatment at the time of the visit (s). This includes the treatment options that were chosen and the ones that were thought about but not chosen after the patient and/or family helped make the decision. For instance, when deciding whether or not to seek medical attention, it is important to think about other levels of care. For example, a psychiatric patient who gets enough help in an outpatient setting or a person with advanced dementia who has an acute condition that would usually require inpatient care but for whom palliative care is the goal and doesn't need to be hospitalized.

Shared decision-making includes asking the patient and/or their family what they want, educating the patient and/or their family, and explaining the risks and benefits of different ways to treat the patient.

There is a possibility that MDM will be affected by role and management responsibilities. ► When a doctor or even other eligible health care provider is trying to report a separate Cpt that includes interpretation and/or report, the interpretation and/or report do not count toward the MDM when choosing a level of E/M services. This is because interpretation and/or report are considered to be part of the reporting of the separate CPT code. If the physician or another qualified health care professional is reporting a separate service for discussion of management with a physician or another qualified health care professional, then the discussion will not be considered by the MDM for choosing a level of E/M services.

When reporting an E/M services code, the Levels of Medical Decision Making (MDM) table, which may be found in Table 1, serves as a reference to aid in selecting the appropriate level of MDM. The following information can be found in the table: the four levels of MDM (i.e., straightforward, low, moderate, and high), as well as the three components of MDM (i.e., the quantity and/or the level of difficulty of the information, as well as how many tasks that needed to be solved during the encounter reviewed and analyzed, and the potential for patient care to result in complications, illness, or even death. Two of the three requirements for a given level of MDM must be satisfied or surpassed before one can be considered qualified for that level of MDM.

The examples provided in the table may or may not be relevant to the particular care settings described. For instance, the decision to admit a patient to the hospital applies to outpatient or nursing facility encounters, whereas the decision to increase the hospital level

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of care (for example, transfer to the intensive care unit) applies to a patient who is already in the hospital or receiving observation care. Please also refer to the introductory instructions provided in the section devoted to each code family.

Components of the Process of Making Medical Decisions

Grade of MDM (Based on two out of three MDM Elements)

The quantity and level of difficulty of the issues that were resolved during the encounter

The scope of the data that has to be examined, including its quantity and/or complexity.

*Each different assessment, sequence, or document contributes to combining a combination of two or three in Category 1 below.

Straightforward Minimal = having only one, usually self-contained, issue

Low Low 2 or greater selfrestraint

little to none

Restricted (Only one category criteria must be met).

*Each different assessment, sequence, or document contributes to combining a combination of two or three in Category 1 below.

Minimal mortality risk associated with further diagnostic tests or therapy

Restricted (Only one category criteria must be met).

Table 1: The Different Levels of Decision-Making in Medical Care (MDM)

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small difficulties or: 1 stable, longterm illness; or 1 mild, moderate sickness or damage;

or 1 unvarying and acute sickness;

1 acute, benign illness or accident needing hospital inpatient or observation level therapy

Category 1: Assessments and paper

Any two of the following options: according to the following: A look back at the previous external notice (s) from each unique source*; A Discussion on the the outcome(s) of each unique test*; Ranking of each in order unique test* or Group 2: Evaluation needing an independent historian (For the categories of independent test interpretation and management or test interpretation discussion, see moderate or high).

Moderate Moderate Moderate

a medical examination or a course of therapy

Moderate chance of getting sick from

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• 1 or more long-term illnesses that become worse, get worse over time, or have adverse reactions from therapies;

■ (It is required that you are successful in at least one of these three areas.)

■ Tests, records, or the findings of an impartial historian make up Category 1. (s)

extra medical examinations or therapy

Only a few illustrations:

• Medication Administration

■ Choose any three options from the list that follows:

■ a review of the preceding external note(s) from each unique source; a review of the result(s) of each unique test; a review of the ordering of each unique test; an evaluation that requires the assistance of an independent historian (s)

■ alternatively, Category 2: Independent Interpretation of Tests or Interpretation of a Test Done Independently

• Decisions on low-risk surgical procedures when a patient or surgical risk considerations are known

• The decision to do a major elective operation without first identifying the patient's or the procedure's risk factors

• Significant social barriers that stand in the way of a

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The decision to do a major elective operation without first identifying the patient's or the procedure's risk factors

Significant social barriers that stand in the way of a diagnosis or treatment OR

Discussion of treatment or interpretation of test results falls under Category 3 and includes the following:

Discussion of treatment or interpretation of test results with an outside physician or other qualified health care professional or suitable source (not separately recorded)

High High

■ One or more long-term illnesses with severe flare-ups, development , or side effects of treatment;

Comprehensive

▪ (Must fit into at least two of the three categories)

Section 1: Testing, recordings, or unbiased historian (s)

Choose any three of the following combinations:

factors that influence one's health

high likelihood of mortality from subsequent diagnostic procedures or treatments

Examples:

▪ Drug treatment that is intensive

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▪ or 1 acute or chronic disease or injury that endangers life or physiological function

● Examination of previous outside note(s) from each distinct source*;

● Examine the outcome(s) of each one of the distinctive tests*;

● Evaluation calls for the participation of a private historian (s) OR Independent analysis of test results constitutes Category 2

An interpretation of a test that was carried out independently by a different physician or by another competent health care professional (which was not separately recorded); Discussions regarding management or interpretations of tests go under Category 3.

▪ Consultation with an external physician or other competent health care expert or suitable source for the

surveillance for toxicity

■ Choices should be made for large elective surgeries with known risk consideratio ns for the patient or the procedure

■ Concerning the decision to do major emergency operation

■ Choices should be made about hospitalizati on or an increase in the degree of hospital treatment

■ As a result of the patient's dismal prognosis, the decision was made not to

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treatment or interpretation of tests (which is not separately recorded)

attempt revive and to reduce the intensity of care.

■ Parenteral controlled substances

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Quantity and Difficulty of Issues Acknowledged at the Meeting

➢ The quantity and severity of the issues that must be solved during the encounter is taken into consideration as one of the criteria for choosing the appropriate level of service. MDM may be impacted in a variety of ways by the simultaneous treatment of many newly emerging or long-standing illnesses. Symptoms may congregate around a certain diagnosis, and each individual symptom does not necessarily indicate a separate health problem. Comorbidities and underlying diseases, in and of themselves, are not considered when choosing a certain degree of E/M services unless these issues are resolved, and the presence of these issues either increases the amount of data that has to be evaluated as well as the complexity of that data analyzed or the possibility of patient treatment resulting in complications, morbidity, or even death This is the case even if the comorbidities and underlying diseases are addressed. The ultimate diagnosis of an illness does not, in and of itself, define the complexity or danger associated with the condition. Extensive assessment may be necessary to arrive at the decision that the signs or symptoms do not represent a very morbid condition. Therefore, presenting symptoms that are likely to indicate a highly morbid ailment might "drive" MDM even in cases where the eventual diagnosis is not a highly morbid disorder. It is important that the examination and/or therapy be appropriate for the likely underlying cause of the disease. The interplay of many issues, each of which is of lesser severity than the others, may, in the aggregate, generate a bigger danger.

In the context of these definitions, the word "risk" refers to the danger that stems from the underlying ailment. The risk that comes from the disease is separate from the risk that comes from the treatment, despite the fact that there is frequently a correlation between the two. The following is a list of definitions for the components of medical decision-making (see Table 1, Levels of Medical Decision-Making): Problem: A disease, condition, ailment, injury, symptom, sign, finding, complaint, or other problem that is addressed during the meeting, with or without a diagnosis being confirmed at the time of the encounter An issue can be characterized as a sickness, condition, ailment, injury, symptom, sign, or discovery, or other matter addressed at the encounter

The issue discussed: A problem is considered to have been addressed or managed when the physician or another competent healthcare provider reporting the service either evaluates or treats the problem during the contact. This includes taking into

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account additional tests or treatments that the patient, parent, guardian, or surrogate might not choose based on the results of a risk-benefit analysis or their own preferences. A notation in the patient's medical record stating that the problem is being managed by another professional without any additional assessment or care coordination being documented does not qualify as the problem being addressed or managed by the physician or any other qualified health care professional reporting the service. The referral does not qualify as being addressed or handled by the physician or other competent health care professional reporting the service since it does not include evaluation (by history, examination, or diagnostic study[ies] or consideration of treatment. The problem that is addressed for hospital inpatient and observation care services is the problem status on the day of the encounter, which may be considerably different from the problem state when the patient was admitted to the hospital. It is an issue that the reporting physician or another trained healthcare professional is managing or co-managing, and it may not be the reason for admission or continuing stay.

Minor issue: A condition that may not necessitate the presence of a physician or other competent health care professional, but the service is delivered under their supervision (see 99211, 99281).

Self-limited or small problem: A condition that follows a clear and prescribed course is of a transitory character and is unlikely to affect health status permanently.

➢ "Stable, chronic sickness" refers to a health condition that is predicted to last for at least one year or until the patient passes away. In the context of determining what constitutes chronicity, conditions are considered to be chronic regardless of whether or not the stage or severity of the ailment varies (for example, both uncontrolled diabetes and managed diabetes are considered to be single chronic conditions). The unique treatment goals for a given patient are what determine what "stable" means in the context of the MDM classification system. A patient is not considered stable if they have not reached their treatment objective, even if their health hasn't changed at all. and there is no immediate risk to their life or ability to function. For instance, a patient who has continuously poor blood pressure control and for whom improved control is a goal is not stable, even though the pressures are unchanging and the patient's condition is not improving. Without therapy, morbidity risk is substantial.

A recent or fresh short-term issue with minimal risk of morbidity is being examined for treatment because of its acuteness and lack of complications. The therapy carries a little to the nonexistent risk of death, and it is anticipated that the patient will make a full recovery without suffering any functional impairment. An acute, uncomplicated sickness is one that does not follow a predetermined and set pattern of progression in its resolution, despite the fact that it is often self-limiting or of a very mild nature.

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Acute illness, simple disease, or accident: A issue that has emerged recently or emerged for the first time in a short period of time and needs treatment while having a minimal risk of morbidity.

Acute conditions that are relatively straightforward but nevertheless require hospitalization and either inpatient or observation level care: A recent or new shortterm problem with a low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation-level setting.

Acute sickness that is stable: A issue that has recently surfaced or become apparent, for which therapy has just begun. The patient's health has stabilized; nevertheless, it is possible that the patient's symptoms will continue to improve over the next days and weeks.

Illness that is chronic and is characterized by aggravation, progression, or treatment-related adverse effects: a chronic illness that is acutely deteriorating, poorly managed, or advancing with the purpose of halting the progression and needing more supportive care or requiring attention to therapy for side effects and the necessity of preventing the advancement.

Undiagnosed new problem with an unknown prognosis: A problem in the differential diagnosis that reflects a circumstance that has a very good chance of leading to a high risk of morbidity if treatment is not administered.

Acute sickness, characterized by the presence of systemic symptoms: is defined as a condition that, in the absence of treatment, carries a high risk of leading to morbidity. See the definitions of a self-limited or minor problem, acute, uncomplicated illness or injury, and general systemic symptoms, such as fever, body aches, or fatigue, that may be treated to alleviate symptoms in a minor illness. These symptoms, along with others like them, maybe treated to alleviate symptoms. Systemic symptoms might refer to a specific system rather than the body as a whole.

acute pain, complex accident: An injury that necessitates treatment and/or examination of bodily systems not immediately related to the injured organ, is severe, has several treatment choices, and/or has a risk of morbidity.

Illness that is prolonged and is characterized by significant exacerbations, progression, or treatment-related adverse effects: The severe worsening or progression of a chronic illness or the severe adverse effects of treatment, both of which carry a considerable risk of morbidity and may call for an increase in the level of care being provided to the patient.

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Acute or long-term disease or damage that places a person's life or their capacity to function properly inside the body in danger: An acute illness with systemic symptoms, a complicated acute accident, a persistent illness or that has worsened and/or progressed over time, or the side effects of medicine that pose a risk to life or bodily function in the near future. If treatment is not administered is an example of an emergent condition. There is a possibility that some symptoms point to a sickness that is not only very likely but also poses a risk to either one's life or their bodily functions. It is possible to put them in this category if the examination and therapy are suitable for this level of potential severity.

Data volume and/or complexity to be examined and interpreted

➢ The quantity and/or the complexity of the data that has to be examined or evaluated during an encounter is one factor that is considered in the selection of the level of services.

The method of making use of the data as a component of the MDM is analyzed. Although the data piece itself may not be susceptible to analysis (for example, glucose), it is still included in the mental processes that are utilized when diagnosing, evaluating, or treating a patient. When findings are presented, it is assumed that any tests that were requested were also performed and evaluated. Therefore, whenever they are ordered during the course of a confrontation, they will count toward that confrontation. The encounter in which the results of tests that were ordered outside utilized an encounter were examined might count toward the encounter total. When there is a recurrent order, each newly obtained result can be recorded in the encounter in which it was obtained. examined if the order keeps coming back. An encounter that includes an order for monthly prothrombin times, for instance, would be counted as one prothrombin time ordered and reviewed. Similarly, a prothrombin time review would count as one prothrombin time ordered. If more future outcomes are evaluated in a subsequent encounter, then that subsequent encounter might count those additional future findings as a single test. The professional component of any service for which whomever, among physicians or other trained medical personnel, is responsible for reporting the E/M. services separately report it is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM. This applies to any service for which the professional component is reported.

Imaging, laboratory, psychometric, or physiologic data might all be included in a test. Tests A clinical laboratory panel (e.g., basic metabolic panel [80047]) is a single test. The CPT

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code set defines the distinction between a single test and several tests in line with its specifications. Pulse oximetry is not considered a test for the purpose of the data that was examined and evaluated.

Unique: A unique test is described by the CPT code set. When several results of the same unique test (e.g., serial blood glucose levels) are compared during an E/M service, count it as one unique test. Even though they are classified with different CPT codes, tests that include components that overlap each other are not considered to be unique. For instance, a complete blood count with differential would include a CBC without differential as well as a platelet count in addition to the standard set of hemoglobin. A physician or other competent health care practitioner in a separate group or different specialization or specialty, or a unique entity, is considered to be a unique source. A unique source may also be an individual. The evaluation of all content derived from any particular source qualifies as one of the MDM's components.

Combining Data Components: In order to accumulate the results of many data elements, it is necessary to combine them. For instance, summing the results of reviewing notes, ordering tests, and going through the results of those tests requires the use of an independent historian. It is not necessary for each individual item type or category to be represented in this manner. A combination of three components would consist of a one-of-a-kind test being ordered, having a note evaluated, and using an impartial historian.

External: Records, correspondence, and test results that come from an external physician or other certified health care provider, institution, or health care organization comes under this domain.

The external medical or another skilled healthcare professional: An independent medical practitioner or another appropriately trained medical worker who is not employed by the same group practice or who belongs to a different medical specialty or specialization. This consists of credentialed professionals who are operating their own businesses independently. It is also possible for the individual to be a facility or organizational providers, such as one from a hospital, nursing home, or home health care service.

Discussion: Discussion includes both listening to one another and speaking with one another. The transaction needs to take place directly, without the participation of any middlemen (e.g., clinical staff or trainees). It is not considered an engaging dialogue to just send chart notes or have written conversations that are included inside progress notes. The debate does not always need to occur on the same day as the encounter in order for it to be counted; nonetheless, it is only counted once and only when it is included in the decisionmaking process of the encounter. It is possible for it to be asynchronous, which means that it does not have to take place in person; nonetheless, it must be started and finished in a very short amount of time (for example, within a day or two).

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Self-governing historian(s): A person (such as a parent, guardian, surrogate, spouse, or witness) who gives a history in addition to the history given by the patient when the patient is unable to give a complete or reliable history (for example, because of a developmental stage, dementia, or psychosis) or when a confirmatory history is thought to be necessary. The requirement for an independent historian is met when there may be disagreements or poor communication between more than one historian, and more than one historian is needed. Translation services are not part of it. The independent history doesn't have to be gotten in person, but it does have to be gotten directly from the historian who is giving it.

Self-governing analysis: The interpretation of a test that has a CPT code and usually has a report or interpretation. This doesn't apply if the doctor or other qualified health care worker who reports the E/M service is also reporting the test or has already done so. A form of interpretation should be written down, but it doesn't have to meet the usual standards for a full test report.

Appropriate source: For the purpose of talking about the management data element (see Table 1, Levels of Medical Decision Making), a lawyer, parole officer, case manager, or teacher who may be involved in the care of the patient is an example of an appropriate source. It doesn't include talking with family or other people who help out.

Patient Management Associated Risk of Complications, Morbidity, and/or Death

The likelihood of complications, morbidity, or death as a result of patient treatment during an encounter is one consideration that goes into determining the degree of service provided. This is a separate concern from the possibility of developing the disorder itself.

➢ Risk: It may be defined as the possibility of something happening or its potential repercussions. The type of occurrence that is being contemplated has a role in the calculation of the appropriate amount of risk to assign. For instance, a high probability of a mild, self-limiting adverse impact of therapy may be considered to have a low risk, whereas a low probability of mortality may be seen to have a high risk. The actions and ways of thinking that are customary for a physician or another trained healthcare professional working in the same field serves as the foundation for risk definitions. It is not necessary for trained doctors to require quantification in order to apply common language use meanings to terminology such as high, medium, low, or minimum risk; nonetheless, quantification may be offered when evidencebased medicine has established probability. In the context of MDM, the level of risk is determined by the repercussions of the problem (or problems) that were addressed

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during the encounter and were successfully resolved. MDM is also a risk factor, and it is associated with the necessity of beginning additional testing, treatment, or hospitalization or forgoing these options. The patient management choices that were part of the reported encounter and were subject to the risk of patient management criteria include those that were made by the reporting physician or another competent healthcare provider.

Morbidity is defined as a condition of disease or functional impairment that is anticipated to last for a significant amount of time, during which function is limited, quality of life is diminished, or there is organ damage that may not be reversible in spite of therapy.

Determinants of health that are social in nature: Conditions of economic and social inequality that have an influence on the physical well-being of individuals as well as entire communities. Instability about one's access to food or shelter is two such examples.

In the case of surgery (whether small or large, elective or emergency, procedure or patient risk), the following applies:

Surgical Procedures: Minor or Major: The decision on whether a surgery is considered minor or major is based on the usual meaning of such terms when used by educated doctors. This is analogous to how the term "risk" is employed. A categorization for surgical packages does not provide definitions for these concepts.

Surgical Procedures: Elective or in Case of Emergency: Elective procedures and emergent or urgent operations explain the time of a procedure when the timing is connected to the state of the patient. Surgical procedures can be either elective or emergent. An elective surgery is often one that is planned in advance (for example, it may be scheduled for a few weeks later), whereas an emergency procedure is typically one that is conducted either immediately or with little delay in order to allow for patient stabilization. Procedures that are elective or emergent can both be modest or substantial, depending on their complexity.

Surgical Procedures Risk Factors Relating to the Patient or the Procedure: The patient and the operation both have a role in determining which risk factors are significant. In the process of risk assessment for both the patient and the operation, the use of evidence-based risk calculators is optional but not obligatory.

"Chemical treatments that require careful supervision because of the risk for toxicity.” A therapeutic agent that has the potential to cause major morbidity or mortality is referred to as a drug that requires intensive monitoring because of its potential for toxicity. The monitoring is carried out, not mainly for the purpose of evaluation, but rather for assessment of these undesirable impacts.

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The surveillance should conform to what is considered standard practice for the drug being monitored, although in certain instances, it may be tailored to the individual patient. The duration of intensive monitoring might be either short or long-term. Long-term intense monitoring is never carried out less frequently than once every three months. The monitoring might be accomplished through the use of imaging, physiologic testing, or laboratory analysis. Monitoring via history or examination does not qualify as appropriate monitoring. During an encounter in which it is taken into consideration for the care of the patient, the monitoring has an effect on the degree of MDM. For instance, while treating cancer with an anticancer drug, it is important to check for cytopenia in between dose cycles. Monitoring glucose levels during insulin therapy is an example of monitoring that does not qualify because the primary reason for doing so is the therapeutic effect (unless severe hypoglycemia is a current and significant concern). Another example of monitoring that does not qualify is annual electrolytes and renal function for a patient who is taking a diuretic because the frequency does not meet the threshold.

Instructions for Choosing the Appropriate Level of Service in Conformity with Time

In the E/M section, certain categories of time-based E/M codes that do not have tiers of services based on MDM (for example, Critical Care Services) employ time in a different way. It is really necessary to go back and look at the instructions for each category.

Because emergency department services are typically delivered on a variable intensity basis, frequently involving multiple encounters with several patients throughout a protracted length of time, time is not a component that is used to describe the levels of emergency medical the range of services that may be obtained at an emergency department.

When reporting E/M service codes using time, the time that is specified in the service descriptors is the time that is utilized to determine the appropriate level of service. The E/M services that fall under the purview of these recommendations need an in-person consultation between the patient and either the treating physician or another certified medical practitioner, as well as the patient's family or caretaker. When billing for services provided in an office or other outpatient setting, use the 99211 code if the total amount of time that is spent on the medical professional or another qualified health care professional is spent supervising clinical personnel who are responsible for providing face-to-face services throughout the encounter.

The entire amount of time spent performing these services should be recorded as the time component when the encounter was coded. It considers both the time spent with the patient face-to-face and/or family/caregiver as well as the time spent by the parties involved on the day of the encounter physician and/or any other competent health care professional(s) that

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did not involve face-to-face interaction with the patient. (it considers the time spent on actions that must be performed by a doctor or another competent health care professional, but do not take into consideration the patient's time constraints. This, however, doesn't take into account the amount of time spent on activities that are typically performed by clinical staff). It considers the time spent with the patient regardless of where the physician or other competent healthcare practitioner is located (e.g., whether on or off the inpatient unit or in or out of the outpatient office). It does not account for any of the time spent in the delivery of a different service that has been independently documented (s).

A shared visit, also known as a split visit, is one that is described as one in which a physician and/or another certified healthcare professional (s) both provide the face-to-face and non-face-to-face work that is relevant to the visit. This type of visit is also known as a split visit. When the length of time is used to choose the right level of service that permits time-based reporting of shared or split visits are allowed, the total time is defined as the time personally spent by the physician, and any the patient is also being evaluated and managed by other certified health care professionals. And/or counseling, educating, as well as the patient, their family, or the caregiver being informed of the results on the date of the encounter. During this time, you may carry out any one of the following actions: This is done when time is used to choose the right Service level at which time-based reporting of joint or multiple visits is permitted. In other words, this step is taken when time is being used to choose the right level of service.

When calculating the total amount of time spent on a shared or split visit, only the time spent on a single visit should be added together. This means that when two or more people jointly meet with or discuss a patient, only one person's time should be included. When a considerable period of time passes, the relevant code for prolonged services may be reported. The length of time spent caring for the patient on the encounter date should be included in the medical record when it serves as the foundation for code selection. The following tasks are included in a doctor's or other qualified healthcare professional's time when they are carried out:

• obtaining the necessary preparations to see the patient (e.g., review of tests)

• gathering and/or examining history that has been gathered independently

• carrying out an examination and/or evaluation that is suitable from a medical standpoint

• Providing counseling and education to the patient, their family, and/or their caregivers

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• placing an order for medicine, diagnostic testing, or surgical procedures

• sending patients to other healthcare experts and communicating with them (where this information is not independently recorded).

• recording patient information in an electronic or another type of health record; independently analyzing outcomes (which are not separately documented) and conveying results to the patient, family, or caregiver; care coordination (not separately reported)

Do not count the following activities:

• the efficiency of several other services, which is detailed in separate reports

• travel

• instruction that is comprehensive and does not confine itself just to the conversation that is necessary for the management with reference to a particular patient

Service Not Listed

It is possible to deliver an E/M service that is not included in the CPT codebook's corresponding entry for that area. When reporting such a service, the relevant unlisted code can be used to denote the service, and it can be identified as a "Special Report," as will be covered in the paragraph that follows this one. The following is a list of the "Unlisted Services" that are associated with the E/M section's accompanying codes:

99429 A preventative medicine service that is not mentioned

Evaluation and management service not included under 99499.

Special Report

If the service is not on the list or if it is rare, changeable, or brand new, a separate report showing the service's appropriateness from a medical standpoint may be required. The relevant information has to contain a sufficient definition or description of the procedure's type, extent, and requirement, as well as the amount of time, effort, and equipment required to offer the service. The intricacy of the symptoms, the definitive diagnosis, important physical findings, diagnostic and therapeutic treatments, concurrent issues, and follow-up care may also be included as additional components.

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Evaluation as well as Administration

Office and Other Outpatient Care

Observational Services at a Health Care Facility

Services for Observational Care and Discharge

➢ (99217 is no longer in use. See 99238, 99239) for information on reporting observation care discharge services.

Initial Care for Observation

New or Existing Patient

(99217 is no longer in use. See 99238, 99239) for information on reporting observation care discharge services.

Follow-up Care and Observation

►(99224, 99225, 99226 have now been removed. To record further observation care, please refer to 99231, 99232, and 99233)

➢ Inpatient Care and Observation Care Services in a Hospital

➢ The first and subsequent assessment and management services offered to hospital inpatients and patients designated as hospital outpatients in "observation status" are reported using the following codes. In addition, codes for hospital inpatient treatment or observation care are utilized in the reporting of partial hospitalization services.

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When a patient is identified or admitted to a hospital with the status of "observation status," it is not required that the patient be situated in an observation area that is specifically defined by the hospital. These codes may be used if the patient is moved to a particular section of the hospital that meets the criteria for this type of location (for example, a separate unit inside the hospital, the emergency department, or another similar area). Report codes 99234, 99235, or 99236 depending on whether the subject was an inpatient or an observer when they were admitted to the hospital and when they were dismissed from the facility.

The total amount of time on the day of the encounter is based on the calendar date. When using MDM or total time as a criterion for code selection, a continuous service that covers the transition between two calendar days is considered a single service and is reported on a single calendar date. All of the time may be applied to the reported date of the service if it is determined that the service was continuous before and through midnight.

Inpatient or Observation Care During the Initial Hospitalization

New or Existing Patient

When reporting a patient's initial interaction with a hospital, whether as an inpatient or in observation status, the following codes should be used.

During the course of the patient's stay, unless the patient has previously obtained professional assistance from the doctor or any other qualified health care professional, or from another physician or any fellow competent medical practitioner working in the same medical field, with the same expertise and subspecialty, who participates in the activities of the same group also, an initial service may be reported. An initial service may also be notified an initial service may also be informed whenever the patient has not obtained any professional services from any other competent healthcare care provider. This is another circumstance in which an initial service may be reported. any other qualified healthcare care professional. An initial service may also be reported when the patient has received professional services from a physician or other qualified healthcare professional who is not affiliated with the same group practice. When advanced-practice nurses and physician assistants work alongside physicians, it is generally understood that they are contributing to the exact same field of specialization and subfield of specialization as the physician. Please read 99477 for information on admission services for neonates who have not yet reached 28 days of age and who require intensive surveillance, frequent interventions, and other intensive care treatments.

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➢ When a patient is admitted to a hospital as an inpatient or for observation during a visit to another site of service (like an emergency room, office, or nursing home), the services at the first site can be reported separately. A significant, separately identifiable service that was performed on the same date by the same physician or some other qualified healthcare professional may be indicated by adding modifier 25 to the other evaluation and management service. This may be done to indicate that the service was performed on the same date.

If the services at a separate site are being reported, and the initial inpatient or observation care service is a consultation service, then you should not record 99221, 99222, 99252, 99253, 99254, or 99255. Instead, report the services at the other site. The subsequent hospital inpatient or observation care codes 99231, 99232, and 99233 are reported by the consultant for the second service on the same day.

If a consultation is performed in anticipation of, or in relation to, an admission by another physician or other qualified health care professional, and then the same consultant performs an encounter once the patient is admitted by the other physician or other qualified health care professional, report the consultant's inpatient encounter with the appropriate subsequent care code (99231, 99232, 99233). In this scenario, the consultation is considered to be subsequent care. This instruction is applicable in either the case where the consultation took place on the same day as the admission or on a date earlier than the admission. Additionally, it applies to consultations that were reported using any code that was suitable (e.g., office or other outpatient visit or office or other outpatient consultation).

Report codes 99234, 99235, and 99236 as applicable for a patient who was admitted to and released from an inpatient or observation status at the same hospital on the same day.

A change from observation level to inpatient status does not constitute a new stay for the purposes of reporting a first hospital inpatient or observation care service.

 99221

Introductory hospital inpatient or observation care, per day, for the assessment and treatment of a patient, which needs a medically adequate history and/or examination and straightforward or low-level medical decision-making. This type of care is provided in a hospital setting. For the purpose of selecting a code based on the total duration on the day of the encounter, the threshold of 40 minutes must be reached or surpassed.

 99222

Initial hospital inpatient or observation care, per day, for the assessment and treatment of a patient, which needs a medically adequate history and/or examination and a moderate level of medical decision-making. This type of care may be provided in a hospital or an observation unit. If the entire duration on the day of

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the encounter is being used as a criterion for code selection, 55 minutes must be fulfilled or surpassed.

 99223 Initial hospital inpatient or observation care, per day, for the assessment and treatment of a patient that needs a medically adequate history and/or examination and a high degree of medical decision-making. If the entire duration on the day of the encounter is being used as a criterion for code selection, 75 minutes must be reached or surpassed.

► (Use the code 993X0 for prolonged services if your service is at least 90 minutes long.)

Inpatient or Observation Services at a Subsequent Date

★▲99231 Care provided in a hospital as an inpatient or under observation, daily, for the assessment and treatment of a patient, which involves a medically adequate history and/or examination and a simple or low degree of medical decision-making. This type of care is provided in hospitals.

To figure out the right code, the whole day of the encounter must last at least 25 minutes, and ideally, it should last longer.

99232 Subsequent hospital inpatient or observation care, per day, for the evaluation and care of a patient, who needs an adequate medical history and/or examination and a moderate level of medical decision-making. This care is given to people who must remain in the hospital for a minimum of one day.

In order to determine the appropriate code, the entire duration of the encounter on the day of the encounter must be at least 35 minutes long and preferably longer.

★▲99233 Subsequent hospital inpatient or observation care, on a per-day basis, for the purpose of evaluating and managing a patient, wherein it is necessary to conduct a medically adequate history and/or examination and a high degree of medical decision-making

When utilizing total time on the day of the encounter for code selection, 50 minutes must be reached or surpassed.

(For operations extending 65 minutes or more, use the extended services code 993X0.)

Services Relating to Hospitalization,

whether as an Inpatient or Observer (This Includes Both Admission and Discharge)

➢ Reporting hospital inpatient or observation care services rendered to patients who were admitted and released on the same date of treatment requires the

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use of the following codes. Refer to codes 99221, 99222, 99223, 99231, 99232, 99233, 99238, and 99239 for information on individuals who were admitted to a hospital as inpatients or for observation care but were discharged on a separate date. The requirements for the codes 99234, 99235, and 99236 are that there must be two or more interactions on the same day, with at least one of these encounters being a discharge experience and the other encounters being initial admission encounters. Refer to codes 99221, 99222, and 99223 for information on a patient who was admitted and discharged within the same encounter (also known as "one encounter"). When you are reporting admission and discharge services that were completed on the same day, do not record 99238, 99239 in combination with 99221, 99222, or 99223. (The code 99463 should be used for discharge services provided to babies who were hospitalized and discharged on the same date.)

➢ 99234 Hospital inpatient or observation care for the management and evaluation of a patient who is recently admitted and released on the same day and who requires a medically necessary history and/or exam as well as straightforward or low-level medical judgments. Care like this is also called observation care.

For code selection, the total time on the day of the encounter must be at least 45 minutes, but it must be longer than that.

➢ 99235 Hospital inpatient or observation care for a patient who needs a medically adequate history and/or exam and a moderate level of medical decision-making. This includes admitting and releasing the patient on the same day.

To find the right code, the whole day of the encounter must last at least 70 minutes, and ideally, it should last longer.

➢ 99236 Hospital inpatient or observation care for a patient who needs a medically adequate history and/or exam and a lot of medical decisions to be made, including admission and discharge on the same day.

To find the right code, the whole day of the encounter must last at least 85 minutes, and ideally, it should last longer.

(Use prolonged services code 993X0 for services lasting 100 minutes or more.)

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Services for hospital inpatients or observation discharge

If a physician or other qualified health care professional spends any amount of time on the date of the encounter preparing a patient for final hospital or observation discharge, regardless of whether that time was spent in a single block or in multiple blocks, the time should be reported using the hospital inpatient or observation discharge day management codes. These codes are to be used for reporting the total amount of time a physician or other qualified healthcare professional spent on the day of the encounter managing the discharge of a hospital inpatient or observation patient.

The codes encompass the last evaluation of the patient, a discussion of the patient's stay in the hospital, instructions for the continuation of treatment to be given to all necessary caregivers, and the compilation of discharge records, prescriptions, and referral forms. Whenever a patient's date of discharge from inpatient or observation status differs from the date of admission, these codes should be used to accurately record all care provided to the patient on the day of release. Patients who were either admitted as inpatients or as observation patients on the day of their discharge should be reported using either code 99234, 99235, or 99236.

Only the attending physician or another qualified healthcare professional in charge of discharging a patient should use the 99238 and 99239 codes. Instructions to the patient and/or family/caregiver and coordination of post-discharge services provided by other physicians or certified health care professionals may be recorded using 99231, 99232, or 99233. More than 30 minutes on the day of the encounter 99238 Management of hospital inpatients or patients under observation who are being discharged on the same day 99239 (For hospital inpatient or observation care including the admission) 99240 Patient or observer in a medical facility

Consultations

When another doctor, nurse, or other competent medical professional asks for advice on how to treat a patient's condition, they are asking for a consultation, which is an examination and management service. It is customary for the asking doctor to cover the cost of the consultation.

An appointment with a doctor or other qualified healthcare expert may involve only a consultation at this time, or it may lead to the beginning of treatment and/or diagnostic procedures at a later date.

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Patient and family-initiated "consultations" that were not sought by a physician or other qualified health care provider or another acceptable source should not be reported using consultation codes (such as a non-clinical social worker, educator, lawyer, or insurance company). A documented report outlining the consultant's assessment and any subsequent recommendations or treatment must be sent to the requesting physician and any other relevant healthcare professionals or sources. If a consultation is needed (for example, by a third-party payer), it should be known that modifier 32 is being used.

➢ When a patient is accepted as an inpatient or for observation, or when they are moved to a different unit, the hospital must be told so that they can bill for their services. In a nursing home, throughout the course of contact in another environment, please refer to First Hospital Inpatient or Initial Nursing Home Care or Observation.

Consultations Conducted Outside of a Healthcare Facility

New or Existing Patient

Consultations given outside of a hospital setting, such as in a patient's home, place of business, or emergency room, can be reported using the following codes. Appropriate codes for established patients visiting the office (99212, 99213, 99214, 99215) or home or residence (99216) for follow-up appointments are recorded whether the appointment is started by the consultant or the patient (99347, 99348, 99349, 99350). New or established patient codes are recorded for office or other outpatient visits or home or resident services that represent a transfer of care (i.e., are given for the management of the patient's overall care or for the care of a specific ailment or issue).

➢ (Use for outpatient consultations that require extended service times. 99417). (99242 is now the reporting number; 99241 has been removed)

 99242 Consultation at a doctor's office or another outpatient setting for a new or established patient that necessitates a brief medical history, a physical exam, and some basic medical judgment. Codes can only be chosen if the entire duration on the day of the encounter is greater than 20 minutes.

 99243 Consultation with a new or established patient in an office setting or another outpatient setting that necessitates a medically adequate history and/or examination but only minimal medical decision-making. Codes can only be chosen if the entire duration on the day of the encounter is greater than 30 minutes.

 99244. Consultation with a new or existing patient in an office setting or another outpatient setting requires a medically adequate history and/or examination and some

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independent medical judgment. Codes can only be chosen if the entire duration on the day of the encounter is greater than 40 minutes.

 99245 Consultation with a new or current patient in an office or other outpatient setting requiring a comprehensive medical history, physical examination, and/or advanced medical decision-making.

When choosing a code based on the overall amount of time spent on the day of the meeting, 55 minutes must be reached or surpassed.

(Prolonged services code 99417 should be used for visits that last 70 minutes or more.)

Consultations for Inpatient or Observation

New or Existing Patient

The codes 99252, 99253, 99254, and 99255 are used to record physician or other qualified healthcare professional consultations given to hospital inpatients, observation-level patients, nursing home residents, or patients in a partial hospital setting when the patient hasn't had any face-to-face medical care from the doctor, another qualified healthcare provider, or another doctor, another qualified healthcare provider of Advanced practice nurses and physician assistants are seen as practicing in the same specialties and subspecialties as doctors when they collaborate with them. A consultant may only report one consultation per admission. For more consultation services during the same hospital stay (99307–99310), use the following inpatient or observation hospital care codes (99231–99233) or the following nursing home care codes. (Use 993X0 for an inpatient observation or consultation that takes a long time; 99251 has been taken away.) Use 99252 to report.

 99252 Inpatient or observation consultation for a new or existing patient requiring an uncomplicated medical assessment and/or history and/or examination. 35 minutes must be reached or surpassed when choosing a code using the total time on the encounter date.

 99253 Inpatient or observation consultation for a new or existing patient requiring a low degree of medical decision-making and a medically adequate history and/or examination. 45 minutes must be fulfilled or surpassed when choosing a code using the total time on the encounter date.

 99254 Inpatient or observation consultation for a new or existing patient, requiring a moderate level of medical decision-making and a medically adequate history and/or examination. When choosing a code, the entire duration on the encounter date must be at least 60 minutes long.

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 99255 For a new or existing patient, an inpatient or observation consultation is necessary, along with a thorough medical history, examination, and decision-making. 80 minutes must pass on the encounter date in order to use the entire time for code selection. (Use the prolonged services code 993X0 for services lasting 95 minutes or more.)

Services for Medical Emergencies

New or Existing Patient

The assessment and management services offered in the emergency room are reported using the following codes. In the emergency room, there is no distinction between new and returning patients. A structured hospital-based facility for the provision of unplanned episodic services to patients who appear to need immediate medical assistance is referred to as an "emergency department." The facility must be open every day of the week.

See the Critical Care guidelines and the numbers 99291, and 99292 for information on critical care services offered in the emergency room. When the patient's health worsens following emergency department treatment and critical care services are given, both emergency department and critical care services may be recorded on the same day

See 99221, 99222, 99223 for the initial observation encounter and 99231, 99232, 99233, 99238, 99239 for subsequent or discharge hospital inpatient or observation visits for assessment and management services provided to a patient in observation status. See 99234, 99235, or 99236 for services related to a hospital inpatient or observation care, including admission and discharge services.

See Initial Hospital Inpatient or Observation Care or Initial Nursing Facility Care to record services when a patient is admitted to a hospital inpatient or observation status or to a nursing facility during an interaction in another location.

Use the relevant CPT code for operations or services designated by a CPT code that can be independently reported on the same day. Report independently identifiable assessment and management services as well as the scope of services included in a surgical package using the applicable modifier(s).

Use office or other outpatient service codes if a patient is seen in the emergency room at the request of a doctor or other competent health care provider (99202-99215).

Useful Hints for Coding

Considerations Regarding Time in the Context of an Emergency Department

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Because emergency department services are often offered on a variable intensity basis, frequently requiring many interactions with several patients over a lengthy period of time, time is not a descriptive factor for the emergency department levels of E/M services.

Guidelines for Choosing the Level of Service Based on Time, CPT Coding Guidelines, Evaluation, and Management

 99281 Visit to an emergency department for the purpose of diagnosis and treatment of a patient who might not need the presence of a doctor or some other certified medical professional in the health care industry

 99282 Visit to an emergency department for the purpose of diagnosis and treatment of a patient, which calls for history and/or examination that is medically suitable and uncomplicated processes for making medical decisions

 99283 Visit to an emergency department for the purpose of diagnosis and treatment of a patient, which calls for history and/or examination that is medically suitable and a poor degree of decision-making in medical matters

 99284 A visit to the emergency room for the purpose of examination and care of a patient, which calls for history and/or examination that is medically suitable and a considerable amount of decision-making in medical matters

 99285 Visit to an emergency department for the purpose of examination and care of a patient, which calls for a history and/or examination that is medically suitable and an advanced degree of clinical decision-making

Useful Hints for Coding

Patients in the Emergency Department Can Be Classified as Either New or Established.

In the emergency department, there is no differentiation made between new patients and those who have already been seen. Any new or established patient who presents themselves for treatment in the emergency department is eligible to have their E/M services reported as part of the emergency department category. Evaluation and management, classification of emergency and medical services, new and established patients, and the CPT Coding Guidelines.

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Different Kinds of Emergency Services

When providing directed emergency treatment or advanced life support, a doctor or other certified healthcare provider is present in the emergency or critical care area of a hospital and converses with ambulance or rescue workers outside the facility via two-way voice communication. For example, telemetry of cardiac rhythm, cardiac and/or pulmonary resuscitation, endotracheal or esophageal obturator airway intubation, intravenous fluid administration, intramuscular, intratracheal, or subcutaneous drug administration, and/or electrical conversion of arrhythmia are all examples of necessary medical procedures that need to be directed.

Emergency care and advanced life support are directed by a doctor or other competent health care professional in 99288.

Services for Nursing Facilities

The evaluation and management services provided to patients in nursing homes and skilled nursing institutions are reported using the following codes. A patient receiving evaluation and management services in a mental health residential treatment facility or an urgent care facility for people with intellectual impairments should also be reported using these codes.

The kind and minimum frequency of evaluations and visits are governed by regulations relevant to the care of nursing facility patients. These rules also specify who is authorized to conduct the first comprehensive visit.

The primary physician(s) and any other licensed healthcare provider(s) in charge of the patient's care at the facility provide these services. The primary physician, also known as the admitting physician, is the medical practitioner who is in charge of the patient's treatment as opposed to other doctors or other trained healthcare workers who could be providing specialty care. In the capacity of a specialist providing consultation or contemporaneous care, doctors or other trained healthcare providers can also provide these services. It could be necessary to use modifiers to specify which individual is providing the service.

Care received at a nursing home for the first time, and care received at a nursing home afterward are the two main subcategories of nursing facility services that are recognized. Both divisions are applicable to both new and current patients.

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The same codes are used to report all care kinds, such as skilled nursing facilities and nursing facility care. To identify the kind of institution (and level of care) where the service(s) are provided, the place of service codes should be recorded.

The quantity and complexity of the issues raised during the encounter are considered when deciding on the degree of medical decision-making (MDM) for nursing facility services. A high-level MDM-type unique to first nursing facility care provided by the primary physician or another qualified healthcare practitioner is acknowledged for this judgment. This kind is the need for rigorous management due to many morbidities: a group of ailments, syndromes, or functional impairments that may call for frequent drug adjustments, as well as additional therapy adjustments and/or reevaluations. The patient faces a serious risk of deteriorating medical (and behavioral) conditions as well as the danger of hospital (re)admission.

The criteria for how much data must be evaluated and processed, how complicated it must be, and how likely it is that patient treatment may result in problems, morbidity, or mortality remain the same.

Initial Care inside a Nursing Facility

New or Existing Patient

➢ When a patient is taken to a nursing home during the course of an interaction at another site of treatment (for example, the emergency department of a hospital or an office), the services provided at the initial site may be recorded separately. A significant, separately identifiable service that was performed on the same date by the same physician or some other qualified healthcare professional may be indicated by adding modifier 25 to the other evaluation and management service. This may be done to indicate that the service was performed on the same date. Do not report 99252, 99253, 99254, 99255, 99304, 99305, or 99306 when services at a separate site are being reported, and the initial nursing facility care service was a consultation service performed by the same physician or other qualified healthcare professional and reported on the same date. In this scenario, the nursing facility care service was performed on the same date. For the second service on the same day, the consultant records the subsequent nursing facility care codes 99307, 99308, 99309, and 99310.

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Initial nursing facility care codes (99304, 99305, 99306) as well as inpatient or observation consultation codes may be used to indicate initial services provided by other physicians and other competent healthcare professionals who are providing consultations (99252, 99253, 99254, 99255). The principle care expert does not need to finish the initial comprehensive services before doing this.

When a patient has not previously received any face-to-face professional services from the doctor, another qualified healthcare provider, or another doctor or other qualified healthcare provider of the exact same specialty and subspecialty who is a member of the same group practice during their stay, an initial service may be reported. When working alongside physicians, advanced practice nurses and physician assistants are regarded as practicing in the same specialty and specialization as the physician. If the patient is a new patient as described in the Evaluation and Management Guidelines, an initial service may also be documented.

Transitions from skilled nursing facility level of care to nursing facility level of care do not count as a new stay for reporting first nursing facility care.

 99304 Initial nursing facility care, per day, for the assessment and treatment of a patient, which needs a medically adequate history and/or examination and a straightforward or low degree of medical decision-making. This care must be provided in a nursing facility. In order to determine the appropriate code, the entire duration on the day of the encounter must be at least 25 minutes long, and ideally, it should be longer.

 99305 Initial nursing facility care, on a per-day basis, for the assessment and management of a patient, which needs a medically adequate history and/or examination and a moderate level of medical decision-making. This type of care is provided in a nursing facility. In order to determine the appropriate code, the entire duration on the day of the encounter must be at least 35 minutes long and preferably longer.

 99306 Initial nursing facility care on a per-day basis for a patient who requires a medically acceptable history and/or examination as well as a high degree of medical decision-making in order to be evaluated and managed. For the purpose of code selection, the entire duration on the day of the encounter must be at least 45 minutes long, and it must be longer than that.

► (Use the prolonged services code 993X0 for any service that is 60 minutes or longer.)

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Subsequent Care at a Nursing Facility

 99307 Subsequent care is provided in a nursing institution on a daily basis for the purpose of the evaluation and treatment of a patient requiring a medically adequate history and/or examination and simple medical decision-making. When selecting a code using the entire time on the day of the encounter, 10 minutes must be reached or surpassed.

 99308 Nursing facility care, per day, for the assessment and treatment of a patient requiring a medically adequate history and/or examination and a low degree of medical decision-making. When selecting a code using the entire time on the day of the encounter, 15 minutes must be reached or surpassed.

 99309 Nursing facility care per day for the evaluation and treatment of a patient requiring a medically adequate history and/or examination and a moderate level of medical decision-making. When selecting a code using the entire time on the day of the encounter, 30 minutes must be reached or surpassed.

 99310 Treatment provided by a nursing facility on a subsequent day for a patient who requires a medically acceptable history and/or examination and a high degree of medical decision-making. This type of care is billed on a perday basis. If the entire time on the day of the encounter is being used to determine the appropriate code, 45 minutes must have elapsed or been surpassed.

➢ (The protracted services code, 993X0, must be used for services that last for 60 minutes or more.)

Services for Nursing Facility Discharge

➢ The entire amount of time a doctor or other qualified healthcare professional spent on a patient's final nursing facility discharge needs to be reported using the nursing facility discharge management codes. Even if the time spent on that date was not continuous, the codes contain, if necessary, a final evaluation of the patient and a discussion of the nursing facility stay. All pertinent caregivers are given instructions on how to complete referral paperwork, discharge records, and medications as well as instructions on how to provide ongoing care. These services call for a face-to-face

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meeting with the patient, their family, or caregivers, which might happen before the patient departs the hospital. The choice of a code is made according to the entire amount of time on the day of the face-to-face discharge management meeting.

➢ 99315 Discharge planning and management for residents of nursing homes; the cumulative amount of time invested on the day of the meeting must not exceed thirty minutes.

➢ 99316 an aggregate amount of time on the day of the meeting more than thirty minutes

Other Services Provided by Nursing Homes

► (99318 has been removed. For information on how to file a report, see forms 99307, 99308, 99309, and 99310)

Providers of Domiciliary, Rest Home (e.g., Boarding Home), and Custodial Care Services

New Patient

➢ The following numbers: 99324, 99325, 99326, 99327, and 99328 were removed: Domiciliary, rest home (also known as boarding homes), and custodial care services for new patients can be found by consulting one of the following service codes: 99341, 99342, 99344, or 99345.

Established Patient

➢ Deleted numbers include 99334, 99335, 99336, and 99337. See home or residence services codes 99347, 99348, 99349, or 99350 for domiciliary rest home (e.g., boarding home) or custodial care services, established patient.

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Oversight Services for Domiciliary, Rest Home (like an Assisted Living Facility), or Home Care Plan

➢ (99339 and 99340 have been removed. See care management services codes 99437 and 99491 or main care management codes 99424, 99425) for domiciliary, rest home [e.g., assisted living facility], or home care plan supervision services.

"Services for the Home or Residence"

The following codes are used to report services for evaluating and managing a home or residence. Home can be a private residence, a place to stay temporarily, or a place to stay for a short time (e.g., a hotel, campground, hostel, or cruise ship).

These codes are also used when the home is an assisted living facility, a group home (that is not licensed as a place where individuals with intellectual disabilities can get care for a while), a custodial care facility, or a residential substance abuse treatment facility.

See Nursing Facility Services for services at a facility providing intermediate care for people with intellectual disabilities and services in a psychiatric residential treatment center.

Do not count travel time when figuring out the code level based on time.

See Initial Hospital Inpatient and Observation Care or Initial Nursing Facility Care to report services when a patient is admitted to a hospital as an inpatient, for observation, or to a nursing home after an encounter in another setting.

New Patient

 99341 Home or residence visit for the assessment and care of a new patient, which needs a medically adequate history and/or examination and

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uncomplicated medical decision-making. This visit must take place at the patient's home or residence. When choosing a code based on the total time on the day of the encounter, there is a 15-minute adjustment that must be made to or taken away from the total time.

 99342 Home or home visit for the assessment and management of a new patient, which needs a medically adequate history and/or examination and minimal levels of medical decision-making. This visit may also be for the purpose of providing care for an existing patient. When choosing a code based on the entire time on the day of the encounter, thirty minutes must be added to or subtracted from the total time.

► (99343 has been removed. Please refer to the following numbers for reporting: 99341, 99342, 99344, and 99345).

➢ 99344 Home or residential visit for the purpose of evaluating and managing a new patient, which entails a medically adequate history and/or examination and a moderate level of medical decision-making on the part of the healthcare provider. When choosing a code based on the total amount of time that passed on the day of the encounter, sixty minutes must have passed or been surpassed.

➢ 99345 Home or residence visit for the purpose of assessment and treatment of a new patient who needs a medically adequate history and/or examination and a high degree of medical decision-making. 99345 Home or residence visit for the evaluation and treatment of an existing patient. In order to determine the appropriate code, the entire duration on the day of the encounter must be at least 75 minutes long, and preferably longer.

► (For services that last 90 minutes or more, please refer to service code 99417)

Established Patient

 99347 Home or residential visit for the assessment and care of an established patient, requiring an uncomplicated medical history and/or examination and appropriate medical examination. 20 minutes must be fulfilled or surpassed when choosing a code using the total time on the encounter date.

 99348 Home or residential visit for the assessment and treatment of an established patient, requiring a modest degree of medical decision-making and a medically adequate history and/or examination. For the purpose of

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choosing a code, the entire duration of the encounter date must be at least 30 minutes long.

 99349 Home or residential visit for the assessment and care of an established patient, requiring a moderate level of medical decision-making and a medically adequate history and/or examination. 40 minutes must be reached or surpassed when choosing a code using the total time on the encounter date.

 99350 Home or residential visit for the assessment and care of an established patient, requiring a high degree of medical decision-making and a medically adequate history and/or examination. When choosing a code, the entire duration on the encounter date must be at least 60 minutes long.

► (For services lasting at least 75 minutes, use code 99417)

Long-Term Services

Prolonged Care with Individualized Attention (Except with Office or Other Outpatient Services)

► (99354, 99355 have been removed. The code 99417 should be used for extended on the day of assessment and management services outpatient treatment, home or resident service, or cognitive assessment and care plan. (99356, and 99357 have been removed. Use the code 993X0) for services related to prolonged assessment and management on the day of an inpatient observation or service provided in a nursing institution.

Extended Service Other Than Face-to-Face Assessment and Management Without Direct Patient Contact

The codes 99358 and 99359 are the ones that need to be used if a prolonged service is provided on a date that differs from the date of a face-to-face assessment and management meeting with the patient and/or a family member or caregiver. It is possible to report the codes 99358 and 99359 for the following. Prolonged services in relation to any evaluation and management service on a date other than the face-to-face service, regardless of whether or not time was used to select the level of the face-to-face service. These codes may be reported for prolonged services in relation to any evaluation and management service on a date other than the face-to-face service.

At a date that is not identical to the date printed on the face-to-face service to which it is associated, this service is to be recorded in connection to the services provided by other physicians or other competent health care professionals, including assessment and management services at any level. Only when the prolonged service happens on a date other

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than the day of the assessment and management service is it permissible to disclose it. Direct patient contact is only required to be reported when it takes place during the evaluation and management service. For instance, a comprehensive record review can be connected to a prior assessment and management service that was carried out at a different point in time. However, it must be related to a service or patient in which (face-to-face) patient care has happened or will occur, and it must be related to the continuous treatment of patients.

Even if the time spent by the doctor or any appropriately licensed healthcare provider on that day is not continuous, the total amount of non-face-to-face time spent by them delivering prolonged service on that date is reported using the codes 99358 and 99359. Regardless of the location of service, the first hour of prolonged service on a particular date is reported using code 99358. Each date should only see one usage of it.

Long-term service that lasts less than 30 minutes in total on a particular day is not recorded individually.

For each additional 30 minutes after the first hour, apply the code 99359. On a certain date, it may also be used to indicate the last 15 to 30 minutes of the extra service.

Continuation of service for less than 15 minutes past the first hour or beyond the last 30 minutes is not recorded individually.

► Do not report 99358, 99359 for time spent without direct patient contact in other services such as care plan oversight services (99374-99380), chronic care management by a physician or other qualified health care professional (99437, 99491), primary care management by a physician or other qualified health care professional (99424, 99425, 99426, 99427), home and outpatient INR monitoring (93792, 93793), medical team conferences (99366-99368), interprofessional (99421, 99422, 99423).

99358 Prolonged patient assessment prior to and/or following direct patient care, and management services; first hour

+99359 each extra 30 minutes (List individually as well as the code for extended service)

(When used together, 99358 and 99359 are recommended.)

► Do not report the following:

(99358, 99359 on the same date of service as 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99242, 99243, 99244, 99245, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284,

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99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345,99347, 99348, 99349, 99350, 99417, 993X0, 99483)

The Complete Length of All Prolonged Services Code(s)

Without having Direct Face-to-Face Contact

Lower than 30 minutes

30-74 minutes (30 minutes - 1 hr. 14 min.)

75 to 104 min (1 hr. 15 min. - 1 hr. 44 min.)

Not reported individually

99358 X 1

99358 X 1 & 99359 X 1

99358 X 1 & 99359 X 2

105 minutes or more (1 hr.45 min. or more) or more for every 30 minutes that are added

Long-term clinical staff services under the direction of a medical professional or other trained health care provider

When a patient is seen in an outpatient or office setting for an evaluation and management (E/M) service that demands a great deal of face-to-face interaction between the clinical staff and the patient, we say that the service is "face-to-face.", family, or caregiver, the codes 99415 and 99416 are utilized. The clinician is under the direct supervision of the attending physician or another certified healthcare practitioner. In addition to the defined E/M services and any additional services offered at the same session as E/M services, this service is recorded.

Even if the time spent by the clinical team on a given date is not continuous, when reporting the entire amount of face-to-face time spent by clinical personnel on a given date delivering prolonged service, codes 99415 and 99416 are utilized. to the patient and/or family/caregiver in the office or another outpatient setting. The prolonged service time does not include any time spent providing separately reported services in addition to the E/M service.

The first hour of prolonged clinical staff service on a certain date is reported using the code 99415. Even though the clinical staff's time on a certain day is not continuous, code 99415 should only be used once on that particular date. Long-term service that lasts less than 30 minutes in total on a particular day is not recorded individually. Use just the face-to-face time that the clinical staff has provided to the patient and/or their family or caregivers when face-to-face time is not continuous.

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It is necessary to record each extra 30 minutes of prolonged clinical staff service using code 99416. This code is required after the first hour of service. In addition, the code 99416 can be utilized to record the final 15-30 minutes of longer service on a certain day. Extended service that is less than 15 minutes longer than the first hour or less than 15 minutes longer than the last 30 minutes is not recorded separately.

It is permissible to submit codes 99415 and 99416 for a maximum of two patients at the same time, and the time recorded for each patient is the time that was spent exclusively caring for that patient. For extended services provided by the physician or another competent health care professional on the day of an office visit or other outpatient assessment and management service (with or without direct patient contact), the fee is as follows:

contact), use 99417. It is not necessary to record numbers 99415 and 99416 in combination with the 99417. There is no requirement for facilities to report either 99415 or 99416.

#99415 Extended clinical staff service (service that exceeds the maximum allowed in the range of the total amount of time spent on the service) whilst an evaluation and management is being carried out

service provided in an outpatient location such as an office or clinic, direct patient interaction with

supervision by a medical professional within the first hour (List separately in addition to the code for

outpatient Evaluation and Management service)

(In combination with numbers 99202, 99203, 99204, 99205, and 99212, use 99415.)

99213, 99214, 99215)

►(Do not report 99415 in combination with 99417) (Do not report 99415 in conjunction with 99417)

#99416 for every additional thirty minutes worked (List individually in addition to the code for longer service).

(In combination with 99415, dial the number 99416)

(Do not report 99416 in combination with 99417) The beginning points for 99415 is 30 minutes beyond the customary clinical staff time for continuing examination of the patient during the office visit. The table titled "Reporting Prolonged Clinical Staff Time" gives the usual clinical staff times for the office or other outpatient main codes, the range of time

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beyond the clinical staff time for which 99415 may be recorded, and the starting point at which 99416 may be reported.

should be

CPT Editorial Panel (Panel) or Executive Committee actions may have an impact on CPT codes and/or descriptions. As a result, the CPT code set's code numbers and/or descriptor language may alter at the time of release. - 47 -

retained. It

noted that future

Code 99417 is used to record the total amount of time that a doctor or other licensed health care provider spent on the given date providing office or other outpatient services, office consultations, or other outpatient evaluation and management services, both with and without having direct patient contact (i.e., 99205, 99215,

Using the code 993X0

of Extensive Time

Code The Typical Time Commitment of Clinical Staff 99415 Time Constraint (Minutes) 99416 The Point of Origin (Minutes) 99202 29 59-103 104 99203 34 64-108 109 99204 41 71-115 116 99205 46 76-120 121 99211 16 46-90 91 99212 24 54-98 99 99213 27 57-101 102 99214 40 70-114 115 99215 45 75-119 120

Extended Service on the Date of an Assessment and Management Service, regardless of Direct Patient Contact

99245, 99345, 99350, 99483).

The Reporting

Spent by Clinical Staff

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Report the entire amount of time that the doctor or other qualified health care provider spent on the day of the inpatient assessment and management service, including time spent both with and without direct patient contact (ie, 99223, 99233, 99236, 99255, 99306, 99310).

Long total time is defined as time that is more than 15 minutes past the deadline for reporting the highest-level main service. Codes 99417 and 993X0 are only used when the principal service has been chosen solely on the basis of time and after a 15-minute delay in reporting the highest-level service. There must have been 15 minutes of time available to record a unit of 99417, 993X0.

Never report the numbers 99417, 993X0 for a time period shorter than 15 minutes.

Once the time in the primary E/M code has gone over by 15 minutes, the starting time unit of 15 minutes should be included when reporting 99417, 993X0. For instance, wait until at least 15 minutes have passed past 60 minutes (i.e., 75 minutes) on the date of the encounter before reporting the first unit of 99417 for a new patient encounter (99205). Report 99417 for an established patient encounter (99215) only when at least 15 minutes have passed past 40 minutes (55 minutes) on the encounter date.

The primary E/M and extended services time does not include time spent conducting separately reported services other than the primary E/M service and prolonged E/M service. See 99358, 99359 for extended services provided on a date other than the date of a face-toface meeting assessment and management meeting with the patient and/or family/caregiver.

See 99415, 99416 for E/M services that need a lot of clinical staff time and may involve face-to-face care from a doctor or other licensed healthcare provider. Notify 99358, 99359, 99415, and 99416 separately from 99417 and 993X0.

Use 99417 in conjunction with 99205, 99215, 99245, 99345, 99350, and 99483 (but do not report 99417 on the same date as 99483). #99417 Prolonged outpatient 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, every 15 minutes of total time (Do not report 99417 for any time unit less than 15 minutes)

#★✚●993X0 Every 15 minutes of total time when the primary service level has been chosen using total time, prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact (List separately in addition to the code of the inpatient and observation Evaluation and Management service) (Use 993X0 in conjunction with 99223, 99233, 99236, 99255, 99306, 99310)

(You should not report 993X0 on the same day of service as 90833, 90836, or 90837) 90838, 99358, 99359)◄

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(It is imperative that you do not record 993X0 for any time unit that is shorter than 15 minutes.)

Cumulative Length of Time Spent in the New Patient Office or Any Other Outpatient Services (use with 99205)

less than 75 minutes

75-89 minutes

90-104 minutes

105 minutes or more

Total Number of Years That a Patient Office or Other Outpatient Services Have Been Established (use with 99215)

less than 55 minutes

55-69 minutes

70-84 minutes

85 minutes or more

Total Amount of Time Spent in the Office or Receiving Other Kinds of Outpatient Consultation Services (use with 99245)

less than 70 minutes

70-84 minutes

80-99 minutes

100 minutes or more

Code(s)

Not reported separately

99205 X 1 and 99417 X 1

99205 X 1 and 99417 X 2

99205 X 1 and 99417 X 3 or more for each additional 15 minutes

Code(s)

Not reported separately

99215 X 1 and 99417 X 1

99215 X 1 and 99417 X 2

99215 X 1 and 99417 X 3 or more for each additional 15 minutes

Code(s)

Not reported separately

99245 X 1 and 99417 X 1

99245 X 1 and 99417 X 2

99245 X 1 and 99417 X 3 or more for each additional 15 minutes◄

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