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 Evaluation and Management (E/M)
Services Guidelines
Evaluation / Management 99202-99499

In addition to the information presented in the further divided into two or more subcategories of E/M
Introduction, several other items unique to this section services. For example, there are two subcategories of office
are defined or identified here. visits (new patient and established patient) and there are
two subcategories of hospital inpatient and observation
care visits (initial and subsequent). The subcategories of
E/M Guidelines Overview E/M services are further classified into levels of E/M
services that are identified by specific codes.
cThe E/M guidelines have sections that are common to
The basic format of codes with levels of E/M services
all E/M categories and sections that are category specific.
based on medical decision making (MDM) or time is the
Most of the categories and many of the subcategories of
same. First, a unique code number is listed. Second, the
service have special guidelines or instructions unique to
place and/or type of service is specified (eg, office or other
that category or subcategory. Where these are indicated,
outpatient visit). Third, the content of the service is
eg, “Hospital Inpatient and Observation Care,” special
defined. Fourth, time is specified. (A detailed discussion
instructions are presented before the listing of the specific
of time is provided in the Guidelines for Selecting Level
E/M services codes. It is important to review the
of Service Based on Time.)
instructions for each category or subcategory. These
guidelines are to be used by the reporting physician or The place of service and service type are defined by the
other qualified health care professional to select the location where the face-to-face encounter with the patient
appropriate level of service. These guidelines do not and/or family/caregiver occurs. For example, service
establish documentation requirements or standards of provided to a nursing facility resident brought to the office
care. The main purpose of documentation is to support is reported with an office or other outpatient code.b
care of the patient by current and future health care
team(s). These guidelines are for services that require a New and Established Patients
face-to-face encounter with the patient and/or family/
cSolely for the purposes of distinguishing between new
caregiver. (For 99211 and 99281, the face-to-face services
and established patients, professional services are those
may be performed by clinical staff.)
face-to-face services rendered by physicians and other
In the Evaluation and Management section (99202- qualified health care professionals who may report
99499), there are many code categories. Each category evaluation and management services. A new patient is
may have specific guidelines, or the codes may include one who has not received any professional services from
specific details. These E/M guidelines are written for the the physician or other qualified health care professional
following categories: or another physician or other qualified health care
professional of the exact same specialty and subspecialty
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J Office or Other Outpatient Services

who belongs to the same group practice, within the past
J Hospital Inpatient and Observation Care Services three years.
J Consultations An established patient is one who has received
J Emergency Department Services professional services from the physician or other qualified
health care professional or another physician or other
J Nursing Facility Services
qualified health care professional of the exact same
J Home or Residence Services specialty and subspecialty who belongs to the same
J Prolonged Service With or Without Direct Patient group practice, within the past three years. See Decision
Contact on the Date of an Evaluation and Tree for New vs Established Patients.
Management Serviceb In the instance where a physician or other qualified
health care professional is on call for or covering for
another physician or other qualified health care
Classification of Evaluation and professional, the patient’s encounter will be classified as it
Management (E/M) Services would have been by the physician or other qualified
health care professional who is not available. When
cThe E/M section is divided into broad categories, such
advanced practice nurses and physician assistants are
as office visits, hospital inpatient or observation care working with physicians, they are considered as working
visits, and consultations. Most of the categories are in the exact same specialty and subspecialty as the
physician.b

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CPT 2023 Evaluation and Management (E/M) Services Guidelines

No distinction is made between new and established cInitial and Subsequent Servicesb
patients in the emergency department. E/M services in
the emergency department category may be reported for cSome categories apply to both new and established
any new or established patient who presents for treatment patients (eg, hospital inpatient or observation care). These
in the emergency department. categories differentiate services by whether the service is

Evaluation / Management 99202-99499

the initial service or a subsequent service. For the purpose
The Decision Tree for New vs Established Patients is of distinguishing between initial or subsequent visits,
provided to aid in determining whether to report the professional services are those face-to-face services
E/M service provided as a new or an established patient rendered by physicians and other qualified health care
encounter. professionals who may report evaluation and
management services. An initial service is when the
Coding Tip patient has not received any professional services from the
Instructions for Use of the CPT Codebook physician or other qualified health care professional or
another physician or other qualified health care
When advanced practice nurses and physician assistants are professional of the exact same specialty and subspecialty
working with physicians, they are considered as working in
the exact same specialty and subspecialty as the physician. A who belongs to the same group practice, during the
“physician or other qualified health care professional” is an inpatient, observation, or nursing facility admission and
individual who is qualified by education, training, licensure/ stay.
regulation (when applicable), and facility privileging (when
A subsequent service is when the patient has received
applicable) who performs a professional service within his or
her scope of practice and independently reports that professional service(s) from the physician or other
professional service. These professionals are distinct from qualified health care professional or another physician or
“clinical staff.” A clinical staff member is a person who works other qualified health care professional of the exact same
under the supervision of a physician or other qualified health specialty and subspecialty who belongs to the same group
care professional, and who is allowed by law, regulation and practice, during the admission and stay.
facility policy to perform or assist in the performance of a
specific professional service but does not individually report In the instance when a physician or other qualified health
that professional service. Other policies may also affect who care professional is on call for or covering for another
may report specific services. physician or other qualified health care professional, the
patient’s encounter will be classified as it would have been
CPT Coding Guidelines, Introduction, Instructions for Use of the
CPT Codebook by the physician or other qualified health care
professional who is not available. When advanced practice

Decision Tree for New vs Established Patients

Received any professional service from the physician or other qualified health
care professional or another physician or other qualified health care professional

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in same group of same specialty within past three years?

Yes No

Exact same specialty? New patient

Yes No

Exact same subspecialty? New patient

Yes No

Established New patient

s=Revised code I=New code c b=Contains new or revised text i=Duplicate PLA test ^=Category I PLA American Medical Association 5
 Evaluation and Management (E/M) Services Guidelines CPT 2023

nurses and physician assistants are working with professional. The extent of history and physical
physicians, they are considered as working in the exact examination is not an element in selection of the level of
same specialty and subspecialty as the physician. these E/M service codes.b
For reporting hospital inpatient or observation care
services, a stay that includes a transition from observation
cLevels of E/M Servicesb
Evaluation / Management 99202-99499

to inpatient is a single stay. For reporting nursing facility

services, a stay that includes transition(s) between skilled
Select the appropriate level of E/M services based on the
nursing facility and nursing facility level of care is the
following:
same stay.b
1. The level of the MDM as defined for each service, or
Services Reported Separately 2. The total time for E/M services performed on the date
of the encounter.
Any specifically identifiable procedure or service (ie,
identified with a specific CPT code) performed on the cWithin each category or subcategory of E/M service
date of E/M services may be reported separately. based on MDM or time, there are three to five levels of
E/M services available for reporting purposes. Levels of
cThe ordering and actual performance and/or E/M services are not interchangeable among the different
interpretation of diagnostic tests/studies during a patient categories or subcategories of service. For example, the
encounter are not included in determining the levels of first level of E/M services in the subcategory of office
E/M services when the professional interpretation of visit, new patient, does not have the same definition as
those tests/studies is reported separately by the physician the first level of E/M services in the subcategory of office
or other qualified health care professional reporting the visit, established patient. Each level of E/M services may
E/M service. Tests that do not require separate be used by all physicians or other qualified health care
interpretation (eg, tests that are results only) and are professionals.b
analyzed as part of MDM do not count as an
independent interpretation, but may be counted as
ordered or reviewed for selecting an MDM level. The
cGuidelines for Selecting Level of
performance of diagnostic tests/studies for which specific Service Based on Medical Decision
CPT codes are available may be reported separately, in Makingb
addition to the appropriate E/M code. The interpretation
of the results of diagnostic tests/studies (ie, professional cFour types of MDM are recognized: straightforward,
component) with preparation of a separate distinctly low, moderate, and high. The concept of the level of
identifiable signed written report may also be reported MDM does not apply to 99211, 99281.
separately, using the appropriate CPT code and, if MDM includes establishing diagnoses, assessing the
required, with modifier 26 appended.b status of a condition, and/or selecting a management
The physician or other qualified health care professional option. MDM is defined by three elements. The elements
may need to indicate that on the day a procedure or are:
service identified by a CPT code was performed, the J The number and complexity of problem(s) that are
patient’s condition required a significant separately addressed during the encounter.
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identifiable E/M service. The E/M service may be caused

J The amount and/or complexity of data to be
or prompted by the symptoms or condition for which the
reviewed and analyzed. These data include medical
procedure and/or service was provided. This circumstance
records, tests, and/or other information that must be
may be reported by adding modifier 25 to the appropriate
obtained, ordered, reviewed, and analyzed for the
level of E/M service. As such, different diagnoses are not
encounter. This includes information obtained from
required for reporting of the procedure and the E/M
multiple sources or interprofessional communications
services on the same date.
that are not reported separately and interpretation of
tests that are not reported separately. Ordering a test is
History and/or Examination included in the category of test result(s) and the review
cE/M codes that have levels of services include a of the test result is part of the encounter and not a
medically appropriate history and/or physical subsequent encounter. Ordering a test may include
examination, when performed. The nature and extent of those considered but not selected after shared decision
the history and/or physical examination are determined making. For example, a patient may request diagnostic
by the treating physician or other qualified health care imaging that is not necessary for their condition and
professional reporting the service. The care team may discussion of the lack of benefit may be required.
collect information, and the patient or caregiver may Alternatively, a test may normally be performed, but
supply information directly (eg, by electronic health due to the risk for a specific patient it is not ordered.
record [EHR] portal or questionnaire) that is reviewed by These considerations must be documented. Data are
the reporting physician or other qualified health care divided into three categories:

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CPT 2023 Evaluation and Management (E/M) Services Guidelines

• Tests, documents, orders, or independent Number and Complexity of Problems

historian(s). (Each unique test, order, or document is
counted to meet a threshold number.) Addressed at the Encounter
• Independent interpretation of tests (not separately cOne element used in selecting the level of service is the
reported). number and complexity of the problems that are

Evaluation / Management 99202-99499

addressed at the encounter. Multiple new or established
• Discussion of management or test interpretation conditions may be addressed at the same time and may
with external physician or other qualified health care affect MDM. Symptoms may cluster around a specific
professional or appropriate source (not separately diagnosis and each symptom is not necessarily a unique
reported). condition. Comorbidities and underlying diseases, in and
J The risk of complications and/or morbidity or of themselves, are not considered in selecting a level of
mortality of patient management. This includes E/M services unless they are addressed, and their
decisions made at the encounter associated with presence increases the amount and/or complexity of data
diagnostic procedure(s) and treatment(s). This includes to be reviewed and analyzed or the risk of complications
the possible management options selected and those and/or morbidity or mortality of patient management.
considered but not selected after shared decision The final diagnosis for a condition does not, in and of
making with the patient and/or family. For example, a itself, determine the complexity or risk, as extensive
decision about hospitalization includes consideration of evaluation may be required to reach the conclusion that
alternative levels of care. Examples may include a the signs or symptoms do not represent a highly morbid
psychiatric patient with a sufficient degree of support condition. Therefore, presenting symptoms that are likely
in the outpatient setting or the decision to not to represent a highly morbid condition may “drive”
hospitalize a patient with advanced dementia with an MDM even when the ultimate diagnosis is not highly
acute condition that would generally warrant inpatient morbid. The evaluation and/or treatment should be
care, but for whom the goal is palliative treatment. consistent with the likely nature of the condition.
Multiple problems of a lower severity may, in the
Shared decision making involves eliciting patient and/or
aggregate, create higher risk due to interaction.b
family preferences, patient and/or family education, and
explaining risks and benefits of management options.b The term “risk” as used in these definitions relates to risk
from the condition. While condition risk and
MDM may be impacted by role and management
management risk may often correlate, the risk from the
responsibility.
condition is distinct from the risk of the management.
cWhen the physician or other qualified health care
cDefinitions for the elements of MDM (see Table 1,
professional is reporting a separate CPT code that
Levels of Medical Decision Making) are:b
includes interpretation and/or report, the interpretation
and/or report is not counted toward the MDM when Problem: A problem is a disease, condition, illness,
selecting a level of E/M services. When the physician or injury, symptom, sign, finding, complaint, or other
other qualified health care professional is reporting a matter addressed at the encounter, with or without a
separate service for discussion of management with a diagnosis being established at the time of the encounter.
physician or another qualified health care professional, cProblem addressed: A problem is addressed or

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the discussion is not counted toward the MDM when managed when it is evaluated or treated at the encounter
selecting a level of E/M services. by the physician or other qualified health care
The Levels of Medical Decision Making (MDM) table professional reporting the service. This includes
(Table 1) is a guide to assist in selecting the level of consideration of further testing or treatment that may not
MDM for reporting an E/M services code. The table be elected by virtue of risk/benefit analysis or patient/
includes the four levels of MDM (ie, straightforward, low, parent/guardian/surrogate choice. Notation in the
moderate, high) and the three elements of MDM (ie, patient’s medical record that another professional is
number and complexity of problems addressed at the managing the problem without additional assessment or
encounter, amount and/or complexity of data reviewed care coordination documented does not qualify as being
and analyzed, and risk of complications and/or morbidity addressed or managed by the physician or other qualified
or mortality of patient management). To qualify for a health care professional reporting the service. Referral
particular level of MDM, two of the three elements for without evaluation (by history, examination, or diagnostic
that level of MDM must be met or exceeded. study[ies]) or consideration of treatment does not qualify
as being addressed or managed by the physician or other
Examples in the table may be more or less applicable to
qualified health care professional reporting the service.
specific settings of care. For example, the decision to
For hospital inpatient and observation care services, the
hospitalize applies to the outpatient or nursing facility
problem addressed is the problem status on the date of
encounters, whereas the decision to escalate hospital level
the encounter, which may be significantly different than
of care (eg, transfer to ICU) applies to the hospitalized or
on admission. It is the problem being managed or
observation care patient. See also the introductory
guidelines of each code family section.b (continued on page 9)

s=Revised code I=New code c b=Contains new or revised text i=Duplicate PLA test ^=Category I PLA American Medical Association 7
 Evaluation and Management (E/M) Services Guidelines CPT 2023

Table 1: Levels of Medical Decision Making (MDM)

cElements of Medical Decision Making

Amount and/or Complexity of Data to Be

Evaluation / Management 99202-99499

Level of MDM Reviewed and Analyzed

(Based on 2 out Number and Complexity *Each unique test, order, or document Risk of Complications and/or
of 3 Elements of of Problems Addressed contributes to the combination of Morbidity or Mortality of Patient
MDM) at the Encounter 2 or combination of 3 in Category 1 below. Management
Straightforward Minimal Minimal or none Minimal risk of morbidity from
J 1 self-limited or minor additional diagnostic testing or
problem treatment
Low Low Limited Low risk of morbidity from additional
J 2 or more self-limited or (Must meet the requirements of at least 1 out of 2 diagnostic testing or treatment
minor problems; categories)
or Category 1: Tests and documents
J 1 stable, chronic illness; J Any combination of 2 from the following:

or • Review of prior external note(s) from each unique

J 1 acute, uncomplicated source*;
illness or injury; • Review of the result(s) of each unique test*;
or • Ordering of each unique test*
J 1 stable, acute illness; or
or Category 2: Assessment requiring an independent
J 1 acute, uncomplicated historian(s)
illness or injury (For the categories of independent interpretation of
requiring hospital tests and discussion of management or test
inpatient or observation interpretation, see moderate or high)
level of care
Moderate Moderate Moderate Moderate risk of morbidity from
J 1 or more chronic (Must meet the requirements of at least 1 out of 3 additional diagnostic testing or
illnesses with categories) treatment
exacerbation, Category 1: Tests, documents, or independent Examples only:
progression, or side historian(s) J Prescription drug management

effects of treatment; J Any combination of 3 from the following: J Decision regarding minor surgery with

or • Review of prior external note(s) from each unique identified patient or procedure risk
J 2 or more stable, source*; factors
chronic illnesses; • Review of the result(s) of each unique test*; J Decision regarding elective major

or • Ordering of each unique test*; surgery without identified patient or

J 1 undiagnosed new • Assessment requiring an independent historian(s) procedure risk factors
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problem with uncertain or J Diagnosis or treatment significantly

prognosis; Category 2: Independent interpretation of tests limited by social determinants of health

or J Independent interpretation of a test performed by

J 1 acute illness with another physician/other qualified health care

systemic symptoms; professional (not separately reported);
or or
J 1 acute, complicated Category 3: Discussion of management or test
injury interpretation
J Discussion of management or test interpretation

with external physician/other qualified health care

professional/appropriate source (not separately
reported)

(continued)

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CPT 2023 Evaluation and Management (E/M) Services Guidelines

Elements of Medical Decision Making

Level of MDM Number and Complexity Amount and/or Complexity of Data to Be Risk of Complications and/or
(Based on 2 out of Problems Addressed Reviewed and Analyzed Morbidity or Mortality of Patient
of 3 Elements of at the Encounter *Each unique test, order, or document contributes Management

Evaluation / Management 99202-99499

MDM) to the combination of 2 or combination of 3 in
Category 1 below.
High High Extensive High risk of morbidity from additional
J 1 or more chronic (Must meet the requirements of at least 2 out of 3 diagnostic testing or treatment
illnesses with severe categories) Examples only:
exacerbation, Category 1: Tests, documents or independent J Drug therapy requiring intensive

progression, or side historian(s) monitoring for toxicity

effects of treatment; J Any combination of 3 from the following: J Decision regarding elective major

or • Review of prior external note(s) from each unique surgery with identified patient or
J 1 acute or chronic source*; procedure risk factors
illness or injury that • Review of the result(s) of each unique test*; J Decision regarding emergency major

poses a threat to life or • Ordering of each unique test*; surgery

bodily function • Assessment requiring an independent historian(s) J Decision regarding hospitalization or
or escalation of hospital-level care
Category 2: Independent interpretation of tests J Decision not to resuscitate or to

J Independent interpretation of a test performed by de-escalate care because of poor

another physician/other qualified health care prognosis
professional (not separately reported); J Parenteral controlled substancesb

or
Category 3: Discussion of management or test
interpretation
J Discussion of management or test interpretation

with external physician/other qualified health care

professional/appropriate source (not separately
reported)

(continued from page 7)

co-managed by the reporting physician or other qualified Acute, uncomplicated illness or injury: A recent or new
health care professional and may not be the cause of short-term problem with low risk of morbidity for which
admission or continued stay. treatment is considered. There is little to no risk of
Minimal problem: A problem that may not require the mortality with treatment, and full recovery without
presence of the physician or other qualified health care functional impairment is expected. A problem that is
professional, but the service is provided under the normally self-limited or minor but is not resolving
physician’s or other qualified health care professional’s consistent with a definite and prescribed course is an

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supervision (see 99211, 99281).b acute, uncomplicated illness.

Self-limited or minor problem: A problem that runs a Acute, uncomplicated illness or injury requiring hospital
definite and prescribed course, is transient in nature, and inpatient or observation level care: A recent or new short-
is not likely to permanently alter health status. term problem with low risk of morbidity for which
treatment is required. There is little to no risk of mortality
cStable, chronic illness: A problem with an expected with treatment, and full recovery without functional
duration of at least one year or until the death of the impairment is expected. The treatment required is delivered
patient. For the purpose of defining chronicity, in a hospital inpatient or observation level setting.
conditions are treated as chronic whether or not stage or
severity changes (eg, uncontrolled diabetes and controlled Stable, acute illness: A problem that is new or recent for
diabetes are a single chronic condition). “Stable” for the which treatment has been initiated. The patient is
purposes of categorizing MDM is defined by the specific improved and, while resolution may not be complete, is
treatment goals for an individual patient. A patient who stable with respect to this condition.
is not at his or her treatment goal is not stable, even if the Chronic illness with exacerbation, progression, or side
condition has not changed and there is no short-term effects of treatment: A chronic illness that is acutely
threat to life or function. For example, a patient with worsening, poorly controlled, or progressing with an intent
persistently poorly controlled blood pressure for whom to control progression and requiring additional supportive
better control is a goal is not stable, even if the pressures care or requiring attention to treatment for side effects.
are not changing and the patient is asymptomatic. The
risk of morbidity without treatment is significant.

s=Revised code I=New code c b=Contains new or revised text i=Duplicate PLA test ^=Category I PLA American Medical Association 9
 Evaluation and Management (E/M) Services Guidelines CPT 2023

Undiagnosed new problem with uncertain prognosis: A by the physician or other qualified health care
problem in the differential diagnosis that represents a professional reporting the E/M services is not counted as
condition likely to result in a high risk of morbidity a data element ordered, reviewed, analyzed, or
without treatment. independently interpreted for the purposes of
Acute illness with systemic symptoms: An illness that determining the level of MDM.
Evaluation / Management 99202-99499

causes systemic symptoms and has a high risk of Test: Tests are imaging, laboratory, psychometric, or
morbidity without treatment. For systemic general physiologic data. A clinical laboratory panel (eg, basic
symptoms, such as fever, body aches, or fatigue in a metabolic panel [80047]) is a single test. The
minor illness that may be treated to alleviate symptoms, differentiation between single or multiple tests is defined
see the definitions for self-limited or minor problem or in accordance with the CPT code set. For the purpose of
acute, uncomplicated illness or injury. Systemic data reviewed and analyzed, pulse oximetry is not a test.
symptoms may not be general but may be single system. Unique: A unique test is defined by the CPT code set.
Acute, complicated injury: An injury which requires When multiple results of the same unique test (eg, serial
treatment that includes evaluation of body systems that blood glucose values) are compared during an E/M
are not directly part of the injured organ, the injury is service, count it as one unique test. Tests that have
extensive, or the treatment options are multiple and/or overlapping elements are not unique, even if they are
associated with risk of morbidity. identified with distinct CPT codes. For example, a CBC
Chronic illness with severe exacerbation, progression, with differential would incorporate the set of
or side effects of treatment: The severe exacerbation or hemoglobin, CBC without differential, and platelet
progression of a chronic illness or severe side effects of count. A unique source is defined as a physician or other
treatment that have significant risk of morbidity and may qualified health care professional in a distinct group or
require escalation in level of care. different specialty or subspecialty, or a unique entity.
Review of all materials from any unique source counts as
Acute or chronic illness or injury that poses a threat to one element toward MDM.
life or bodily function: An acute illness with systemic
symptoms, an acute complicated injury, or a chronic Combination of Data Elements: A combination of
illness or injury with exacerbation and/or progression or different data elements, for example, a combination of
side effects of treatment, that poses a threat to life or notes reviewed, tests ordered, tests reviewed, or
bodily function in the near term without treatment. independent historian, allows these elements to be
Some symptoms may represent a condition that is summed. It does not require each item type or category
significantly probable and poses a potential threat to life to be represented. A unique test ordered, plus a note
or bodily function. These may be included in this reviewed and an independent historian would be a
category when the evaluation and treatment are combination of three elements.
consistent with this degree of potential severity.b External: External records, communications and/or test
results are from an external physician, other qualified
cAmount and/or Complexity of Data health care professional, facility, or health care
organization.
to Be Reviewed and Analyzedb
External physician or other qualified health care
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cOne element used in selecting the level of services is the

professional: An external physician or other qualified
amount and/or complexity of data to be reviewed or health care professional who is not in the same group
analyzed at an encounter.b practice or is of a different specialty or subspecialty. This
Analyzed: The process of using the data as part of the includes licensed professionals who are practicing
MDM. The data element itself may not be subject to independently. The individual may also be a facility or
analysis (eg, glucose), but it is instead included in the organizational provider such as from a hospital, nursing
thought processes for diagnosis, evaluation, or treatment. facility, or home health care agency.
Tests ordered are presumed to be analyzed when the Discussion: Discussion requires an interactive exchange.
results are reported. Therefore, when they are ordered The exchange must be direct and not through
during an encounter, they are counted in that encounter. intermediaries (eg, clinical staff or trainees). Sending
Tests that are ordered outside of an encounter may be chart notes or written exchanges that are within progress
counted in the encounter in which they are analyzed. In notes does not qualify as an interactive exchange. The
the case of a recurring order, each new result may be discussion does not need to be on the date of the
counted in the encounter in which it is analyzed. For encounter, but it is counted only once and only when it is
example, an encounter that includes an order for monthly used in the decision making of the encounter. It may be
prothrombin times would count for one prothrombin asynchronous (ie, does not need to be in person), but it
time ordered and reviewed. Additional future results, if must be initiated and completed within a short time
analyzed in a subsequent encounter, may be counted as a period (eg, within a day or two).
single test in that subsequent encounter. Any service for
which the professional component is separately reported

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CPT 2023 Evaluation and Management (E/M) Services Guidelines

cIndependent historian(s): An individual (eg, parent, management decisions made by the reporting physician
guardian, surrogate, spouse, witness) who provides a or other qualified health care professional as part of the
history in addition to a history provided by the patient reported encounter.b
who is unable to provide a complete or reliable history Morbidity: A state of illness or functional impairment
(eg, due to developmental stage, dementia, or psychosis) that is expected to be of substantial duration during

Evaluation / Management 99202-99499

or because a confirmatory history is judged to be which function is limited, quality of life is impaired, or
necessary. In the case where there may be conflict or poor there is organ damage that may not be transient despite
communication between multiple historians and more treatment.
than one historian is needed, the independent historian
requirement is met. It does not include translation Social determinants of health: Economic and social
services. The independent history does not need to be conditions that influence the health of people and
obtained in person but does need to be obtained directly communities. Examples may include food or housing
from the historian providing the independent insecurity.
information. Surgery (minor or major, elective, emergency,
Independent interpretation: The interpretation of a test procedure or patient risk):
for which there is a CPT code, and an interpretation or Surgery—Minor or Major: The classification of
report is customary. This does not apply when the surgery into minor or major is based on the common
physician or other qualified health care professional who meaning of such terms when used by trained clinicians,
reports the E/M service is reporting or has previously similar to the use of the term “risk.” These terms are
reported the test. A form of interpretation should be not defined by a surgical package classification.
documented but need not conform to the usual standards
Surgery—Elective or Emergency: Elective procedures
of a complete report for the test.b
and emergent or urgent procedures describe the timing
Appropriate source: For the purpose of the discussion of of a procedure when the timing is related to the
management data element (see Table 1, Levels of Medical patient’s condition. An elective procedure is typically
Decision Making), an appropriate source includes planned in advance (eg, scheduled for weeks later),
professionals who are not health care professionals but while an emergent procedure is typically performed
may be involved in the management of the patient (eg, immediately or with minimal delay to allow for patient
lawyer, parole officer, case manager, teacher). It does not stabilization. Both elective and emergent procedures
include discussion with family or informal caregivers. may be minor or major procedures.
Surgery—Risk Factors, Patient or Procedure: Risk
cRisk of Complications and/or factors are those that are relevant to the patient and
Morbidity or Mortality of Patient procedure. Evidence-based risk calculators may be
Managementb used, but are not required, in assessing patient and
procedure risk.
One element used in selecting the level of service is the
cDrug therapy requiring intensive monitoring for
risk of complications and/or morbidity or mortality of
patient management at an encounter. This is distinct toxicity: A drug that requires intensive monitoring is a
therapeutic agent that has the potential to cause serious

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from the risk of the condition itself.
morbidity or death. The monitoring is performed for
cRisk: The probability and/or consequences of an event. assessment of these adverse effects and not primarily for
The assessment of the level of risk is affected by the assessment of therapeutic efficacy. The monitoring should
nature of the event under consideration. For example, a be that which is generally accepted practice for the agent
low probability of death may be high risk, whereas a high but may be patient-specific in some cases. Intensive
chance of a minor, self-limited adverse effect of treatment monitoring may be long-term or short-term. Long-term
may be low risk. Definitions of risk are based upon the intensive monitoring is not performed less than quarterly.
usual behavior and thought processes of a physician or The monitoring may be performed with a laboratory test,
other qualified health care professional in the same a physiologic test, or imaging. Monitoring by history or
specialty. Trained clinicians apply common language examination does not qualify. The monitoring affects the
usage meanings to terms such as high, medium, low, or level of MDM in an encounter in which it is considered
minimal risk and do not require quantification for these in the management of the patient. An example may be
definitions (though quantification may be provided when monitoring for cytopenia in the use of an antineoplastic
evidence-based medicine has established probabilities). agent between dose cycles. Examples of monitoring that
For the purpose of MDM, level of risk is based upon do not qualify include monitoring glucose levels during
consequences of the problem(s) addressed at the insulin therapy, as the primary reason is the therapeutic
encounter when appropriately treated. Risk also includes effect (unless severe hypoglycemia is a current, significant
MDM related to the need to initiate or forego further concern); or annual electrolytes and renal function for a
testing, treatment, and/or hospitalization. The risk of patient on a diuretic, as the frequency does not meet the
patient management criteria applies to the patient threshold.b

s=Revised code I=New code c b=Contains new or revised text i=Duplicate PLA test ^=Category I PLA American Medical Association 11
 Evaluation and Management (E/M) Services Guidelines CPT 2023

cGuidelines for Selecting Level of Physician or other qualified health care professional time
includes the following activities, when performed:
Service Based on Timeb
J preparing to see the patient (eg, review of tests)
cCertain categories of time-based E/M codes that do not
have levels of services based on MDM (eg, Critical Care J obtaining and/or reviewing separately obtained history
Evaluation / Management 99202-99499

Services) in the E/M section use time differently. It is J performing a medically appropriate examination and/
important to review the instructions for each category. or evaluation
Time is not a descriptive component for the emergency J counseling and educating the patient/family/caregiver
department levels of E/M services because emergency
J ordering medications, tests, or procedures
department services are typically provided on a variable
intensity basis, often involving multiple encounters with J referring and communicating with other health care
several patients over an extended period of time. professionals (when not separately reported)
When time is used for reporting E/M services codes, the J documenting clinical information in the electronic or
time defined in the service descriptors is used for selecting other health record
the appropriate level of services. The E/M services for J independently interpreting results (not separately
which these guidelines apply require a face-to-face reported) and communicating results to the patient/
encounter with the physician or other qualified health family/caregiver
care professional and the patient and/or family/caregiver.
For office or other outpatient services, if the physician’s or J care coordination (not separately reported)b
other qualified health care professional’s time is spent in Do not count time spent on the following:
the supervision of clinical staff who perform the face-to- J the performance of other services that are reported
face services of the encounter, use 99211. separately
For coding purposes, time for these services is the total J travel
time on the date of the encounter. It includes both the
face-to-face time with the patient and/or family/caregiver J teaching that is general and not limited to discussion
and non-face-to-face time personally spent by the that is required for the management of a specific
physician and/or other qualified health care patient
professional(s) on the day of the encounter (includes time
in activities that require the physician or other qualified
health care professional and does not include time in Unlisted Service
activities normally performed by clinical staff ). It includes
time regardless of the location of the physician or other An E/M service may be provided that is not listed in this
qualified health care professional (eg, whether on or off section of the CPT codebook. When reporting such a
the inpatient unit or in or out of the outpatient office). It service, the appropriate unlisted code may be used to
does not include any time spent in the performance of indicate the service, identifying it by “Special Report,” as
other separately reported service(s). discussed in the following paragraph. The “Unlisted
Services” and accompanying codes for the E/M section
A shared or split visit is defined as a visit in which a are as follows:
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physician and other qualified health care professional(s)

both provide the face-to-face and non-face-to-face work 99429 Unlisted preventive medicine service
related to the visit. When time is being used to select the
99499 Unlisted evaluation and management service
appropriate level of services for which time-based
reporting of shared or split visits is allowed, the time
personally spent by the physician and other qualified
health care professional(s) assessing and managing the
Special Report
patient and/or counseling, educating, communicating An unlisted service or one that is unusual, variable, or
results to the patient/family/caregiver on the date of the new may require a special report demonstrating the
encounter is summed to define total time. Only distinct medical appropriateness of the service. Pertinent
time should be summed for shared or split visits (ie, when information should include an adequate definition or
two or more individuals jointly meet with or discuss the description of the nature, extent, and need for the
patient, only the time of one individual should be procedure and the time, effort, and equipment necessary
counted). to provide the service. Additional items that may be
When prolonged time occurs, the appropriate prolonged included are complexity of symptoms, final diagnosis,
services code may be reported. The total time on the date pertinent physical findings, diagnostic and therapeutic
of the encounter spent caring for the patient should be procedures, concurrent problems, and follow-up care.
documented in the medical record when it is used as the
basis for code selection.

12 *=Telemedicine X=Audio-only :=Add-on code ~=FDA approval pending #=Resequenced code H=Modifier 51 exempt 333=See p xix for details