E/M Guidelines?

Keywords/Questions Notes (Right Column)

E/M guidelines help physicians/healthcare

professionals select the correct level of service. They
What are E/M Guidelines?
apply to face-to-face encounters with
patients/caregivers.

Are E/M guidelines

No, they do not set documentation requirements but
documentation
help support patient care.
requirements?

Which codes allow non-

physician staff to perform 99211 and 99281 may be performed by clinical staff.
services?

1. Office or Other Outpatient Services

2. Hospital Inpatient & Observation Care
3. Consultations
What are the main E/M 4. Emergency Department Services
categories? 5. Nursing Facility Services
6. Home or Residence Services
7. Prolonged Services (with/without direct
contact)

1. By category (e.g., office visit, hospital visit,

consultation).
How are E/M services 2. By subcategory (e.g., new vs. established
classified? patient).
3. By level of service (determined by Medical
Decision Making (MDM) or time).

The physical location where the face-to-face

What determines the
encounter occurs (e.g., an office visit for a nursing
place of service?
facility resident is still coded as an office visit).

Summary (Bottom Section)

E/M guidelines help providers select the correct level of service but do not
dictate documentation rules. Services must involve face-to-face interactions
except for 99211 and 99281. E/M categories include office visits, inpatient visits,
consultations, emergency services, and more. Classification is based on category,
subcategory, and level of service using MDM or time.
 New and Established Patients

Keywords/Questions Notes (Right Column)

A patient who has not received professional

services from the physician or another provider
What defines a new patient?
of the same specialty/subspecialty in the
same group within the past 3 years.

A patient who has received professional

What defines an established services from the physician or another provider
patient? of the same specialty/subspecialty in the
same group within the past 3 years.

How are patients classified The patient’s status is based on the regular
when a provider is on call? provider, not the covering/on-call provider.

How are advanced practice They are considered to be in the same

nurses (APNs) and physician specialty/subspecialty as the physician they
assistants (PAs) classified? work with.

Does the emergency

department (ED) distinguish No, all ED visits are coded the same, whether
between new and the patient is new or established.
established patients?

What is the Decision Tree for A flowchart that helps determine whether a
New vs. Established patient encounter should be coded as new or
Patients? established.

Summary (Bottom Section)

A new patient has not received care from a provider of the same
specialty/subspecialty in the same group within 3 years, while an
established patient has.
When providers are on call, classification is based on the regular provider.
Advanced practice nurses (APNs) and physician assistants (PAs) are
classified under the same specialty as their supervising physician.
Emergency department (ED) codes do not differentiate between new and
established patients. The Decision Tree helps determine the correct patient
status.
 Initial and Subsequent Services

Keywords/Questions Notes (Right Column)

Categories like hospital inpatient, observation care,

What categories use
and nursing facility services use initial vs.
initial and subsequent
subsequent service classification instead of new vs.
service distinctions?
established patients.

A service provided when a patient has not received

professional services from the physician or another
What is an initial
provider of the same specialty/subspecialty in the
service?
same group during the inpatient, observation, or
nursing facility stay.

A service provided when a patient has received

What is a subsequent professional services from the physician or another
service? provider of the same specialty/subspecialty in the
same group during the same admission/stay.

How are services

The classification is based on the regular provider, not
classified when a
the covering or on-call provider.
provider is on call?

How are APNs and PAs They are considered to be in the same
classified in terms of specialty/subspecialty as the physician they work
specialty? with.

- Observation to inpatient = Same stay

How are transitions in
- Skilled nursing facility (SNF) to nursing facility
care classified?
(NF) level of care = Same stay

Summary (Bottom Section)

Initial and subsequent service classification is used in hospital inpatient,
observation, and nursing facility settings. An initial service occurs when the
patient has not received services from a provider of the same
specialty/subspecialty in the same group during the same admission or
stay. A subsequent service occurs when the patient has already received care
from such a provider during the same stay. If a provider is on call, the
classification remains as it would have been for the regular provider. Transitions
from observation to inpatient or between different levels of nursing care
count as the same stay for coding purposes.
 Services Reported Separately

Keywords/Questions Notes (Right Column)

Can separately identifiable Yes, procedures or services that have a specific

procedures be reported on the CPT code can be reported separately from
same day as E/M services? the E/M service.

No, ordering, performing, and interpreting

Are diagnostic tests/studies
diagnostic tests/studies are not included in
included in determining the
E/M level determination if a separate CPT
E/M level?
code is reported for the interpretation.

Tests that are results only (e.g., labs without

How are tests that do not interpretation) are counted as ordered or
require separate interpretation reviewed under Medical Decision Making
handled? (MDM) but not as an independent
interpretation.

- If a test requires a separate written report,

the interpretation is reported separately.
How is the interpretation of
- Use the appropriate CPT code and append
diagnostic tests reported?
modifier 26 if reporting only the professional
component.

- Modifier 25 is added to the E/M code if a

What if an E/M service is
significant, separately identifiable E/M
significant and separate from a
service was performed.
procedure performed on the
- The E/M service does not need a different
same day?
diagnosis from the procedure.

Summary (Bottom Section)

Procedures and services with their own CPT codes can be reported separately
from E/M services. Diagnostic tests and studies do not factor into E/M level
selection if their interpretation is reported separately. Tests that do not
require interpretation can be counted as ordered/reviewed under MDM. If a
procedure and an E/M service are performed on the same day, Modifier 25 is used
to indicate a significant, separately identifiable E/M service, even if both have
the same diagnosis.
 History and/or Examination & Levels of E/M
Services

Keywords/Questions Notes (Right Column)

A medically appropriate history and/or

Is history and physical
physical examination is included when
examination required for E/M
performed, but its extent is determined by the
coding?
treating provider.

- The care team may collect patient information.

Who can collect history and - The patient/caregiver can provide info via
exam information? EHR portal or questionnaire.
- The physician or QHP must review the
information.

Does history/exam impact E/M No, history and physical examination are not
level selection? elements in selecting the level of E/M service.

- Medical Decision Making (MDM) or

What determines the level of
- Total time spent on the encounter (on the
E/M services?
same date).

No, E/M levels differ by category and

Are E/M levels
subcategory. Example: A Level 1 new patient
interchangeable across
office visit ≠ Level 1 established patient office
categories/subcategories?
visit.

All physicians and other qualified

Who can report E/M levels? healthcare professionals (QHPs) can use E/M
codes.

Summary (Bottom Section)

The extent of history and physical examination is determined by the provider
but does not affect E/M level selection. Instead, E/M levels are based on either
Medical Decision Making (MDM) or total time spent on the same date. Care
teams and patients can provide information, but the provider must review it.
E/M levels vary across categories (e.g., new vs. established patients), and all
physicians and QHPs can use them.
 Medical Decision Making (MDM)
Topic: Selecting Level of E/M Services Based on MDM

Keywords/Questions Notes (Right Column)

Four types:
- Straightforward
How many types of MDM
- Low
are there?
- Moderate
- High

Three key elements:

1. Number & complexity of problems
addressed
What elements define
2. Amount/complexity of data reviewed &
MDM?
analyzed
3. Risk of complications, morbidity, or
mortality

Do MDM rules apply to

No, MDM does not apply to these codes.
99211 and 99281?

- Medical records, tests, orders, documents

- Independent historian input
What counts as data in - Independent interpretation of tests (not
MDM? separately reported)
- Discussion with external physician/QHP (not
separately reported)

- Ordering a test counts toward MDM.

How does ordering vs. - Reviewing test results is part of the same
reviewing tests affect encounter and does not count separately.
MDM? - If a test is considered but not performed,
documentation is required.

- Low Risk: OTC medications, minor surgery

with no risk factors.
- Moderate Risk: Prescription drug
What are examples of risk management, elective surgery without risk
in MDM? factors.
- High Risk: Drug therapy requiring intensive
monitoring, emergency major surgery, DNR
decision.

How many MDM elements At least two out of three elements must be met
must be met for a level? to assign a specific MDM level.
 Keywords/Questions Notes (Right Column)

No, MDM levels are specific to each E/M

Is MDM interchangeable
category and are not interchangeable (e.g.,
across E/M categories?
Office Visit vs. Hospital Visit).

Summary (Bottom Section)

MDM is classified into four levels: Straightforward, Low, Moderate, and
High. It is based on three elements: (1) Number/complexity of problems,
(2) Data reviewed/analyzed, and (3) Risk of
complications/morbidity/mortality. At least two of the three elements must
be met to determine the level of MDM. Ordering tests counts, but
reviewing them is part of the same encounter. MDM does not apply to
99211 and 99281. Examples of risk include minor procedures for low risk,
prescription drug management for moderate risk, and ICU admissions or
emergency surgery for high risk.

Number & Complexity of Problems in MDM

Keywords/Questions Notes (Right Column)

What does "Number & One of the three elements used to determine the
Complexity of Problems" level of Medical Decision Making (MDM) in E/M
mean in MDM? coding.

Only if they are actively addressed and increase

Are comorbidities
the amount of data reviewed or risk of
considered in MDM?
complications.

No. Symptoms leading to a highly morbid

Does the final diagnosis
condition impact MDM even if the final diagnosis
determine MDM complexity?
is not severe.

A problem is addressed when it is evaluated or

What does "problem
treated by the provider, including consideration of
addressed" mean?
further testing or treatment.

No. A provider must perform evaluation (history,

Does referral alone count as
exam, or tests) or consider treatment for a
addressing a problem?
problem to be considered "addressed."

How is problem complexity Minimal, Low, Moderate, High complexity

 Keywords/Questions Notes (Right Column)

classified? based on severity and risk.

- Minimal problem: Does not require provider

presence (99211, 99281).
- Self-limited/minor problem: Transient, no
lasting health impact.
- Stable, chronic illness: Expected duration ≥1
year, controlled.
- Acute, uncomplicated illness/injury: Short-
term, low risk of morbidity.
- Chronic illness with exacerbation: Worsening,
What are examples of
poor control, or side effects of treatment.
problem types?
- Acute illness with systemic symptoms: High
risk of morbidity without treatment.
- Acute, complicated injury: Extensive or
involving multiple systems.
- Chronic illness with severe exacerbation:
High morbidity, may need escalation of care.
- Acute/chronic illness posing threat to life or
function: Immediate risk of severe morbidity or
mortality.

Summary (Bottom Section)

The number and complexity of problems addressed is a key factor in MDM
level selection. Only problems evaluated or treated count toward MDM, and
comorbidities are only considered if they increase risk or require
additional data review. The final diagnosis alone does not determine MDM
complexity—symptoms suggesting a severe condition can increase MDM even if
the diagnosis is benign. Problem severity is categorized from minimal to high
complexity, with severe chronic conditions or life-threatening conditions
requiring escalation of care contributing to high MDM.

Amount & Complexity of Data in MDM

Keywords/Questions Notes (Right Column)

What does "Amount & One of the three elements used to determine
Complexity of Data" mean Medical Decision Making (MDM) level based on
in MDM? the data reviewed or analyzed.

What is "analyzed" data? Information used in the decision-making process

(e.g., test results, medical records). Ordering a test
 Keywords/Questions Notes (Right Column)

counts as analyzing it.

Are separately reported No, if a provider separately reports an

professional services interpretation (e.g., radiology read with CPT code),
counted? it does not count towards MDM.

- Each unique test counts once per encounter.

- Recurring orders (e.g., monthly labs) count once
How are tests counted? per encounter when reviewed.
- Lab panels (e.g., CBC, BMP) count as one test
based on CPT.

- Unique test: Defined by CPT code (e.g., CBC and

What does "unique" mean hemoglobin alone do not count separately).
in data review? - Unique source: Different provider, specialty, or
entity (e.g., external hospital records).

- External records, communications, or test

What are external records
results are from a provider outside the reporting
or sources?
physician’s group or specialty.

- Must be direct and two-way (not through

intermediaries).
What is an "interactive
- Can be asynchronous (e.g., completed within 1-2
discussion"?
days).
- Sending chart notes alone does not qualify.

- Parent, guardian, spouse, surrogate, or witness who

Who qualifies as an provides history when the patient is unreliable
independent historian? (e.g., dementia, psychosis, communication issues).
- Does not include translators.

- Interpretation of a test that has a CPT code but is

What is an independent not separately reported.
interpretation? - Does not require a full report, but a documented
interpretation is needed.

- Non-healthcare professionals involved in patient

Who is an "appropriate management (e.g., lawyer, parole officer, case
source" in MDM? manager, teacher).
- Does not include family or informal caregivers.
Summary (Bottom Section)
The amount and complexity of data reviewed is a key factor in MDM level
selection. Data must be actively analyzed to count toward MDM. Ordering a
test counts, but separately reported services do not. Unique tests and
sources must be distinct based on CPT code or provider specialty. Discussions
must be direct and interactive, and independent historians are used when
the patient cannot provide a reliable history. Interpretations count if not
separately reported, and non-healthcare professionals like case managers
may be counted as appropriate sources in MDM.

Risk of Complications & Morbidity/Mortality in

MDM
Keywords/Questions Notes (Right Column)

The probability and consequences of an

What does "risk" mean in
event occurring due to patient management
MDM?
decisions, not just the condition itself.

- Based on clinical judgment (no need for

exact quantification).
How is "risk" assessed? - Considers consequences of problems
addressed and whether further testing,
treatment, or hospitalization is needed.

Illness or functional impairment expected to

What is morbidity? be long-term, limiting function, reducing quality
of life, or causing potential organ damage.

What are social determinants Economic or social conditions that impact health
of health? (e.g., food or housing insecurity).

- Minor vs. Major: Based on common clinical

definitions (not surgical package rules).
How is surgery classified in - Elective vs. Emergency: Elective is planned,
MDM? emergency is immediate or urgent.
- Patient/Procedure Risk Factors: Can be
assessed using risk calculators (optional).

- A drug that may cause serious morbidity

or death.
What qualifies as "drug
- Monitoring is for toxicity, not just
therapy requiring intensive
therapeutic effect.
monitoring for toxicity"?
- Must be performed at least quarterly and
use lab, physiologic, or imaging tests.
 Keywords/Questions Notes (Right Column)

- Valid Example: Monitoring cytopenia for

chemotherapy between doses.
What are examples of - Invalid Example: Checking glucose for insulin
intensive drug monitoring? therapy (focuses on efficacy, not toxicity).
- Invalid Example: Annual kidney function for a
diuretic (not frequent enough).

Summary (Bottom Section)

Risk in MDM refers to the consequences of patient management decisions,
not just the condition itself. Surgery risk is based on clinical judgment, with
elective vs. emergency procedures categorized separately from major vs. minor
procedures. Drug therapy requiring intensive monitoring for toxicity must
involve serious morbidity risk and monitoring at least quarterly via lab,
imaging, or physiologic tests (not just clinical exams or standard treatment
monitoring). Social determinants of health like housing insecurity may
contribute to higher patient risk.

Time-Based E/M Services

Keywords/Questions Notes (Right Column)

- Time is used differently for time-based E/M codes,

How is time used in especially for Critical Care services.
E/M codes? - Time is not used for emergency department services
(due to variable intensity).

- Face-to-face time with the patient/family/caregiver.

- Non-face-to-face time spent by the physician or other
What counts toward qualified health care professional (e.g., reviewing tests,
the total time? coordinating care).
- Time on the date of the encounter regardless of
location (e.g., in/out of office, inpatient unit).

- Time spent performing separately reported services

What is excluded (e.g., procedures).
from time? - Travel time.
- General teaching not related to patient management.

What is a shared or A visit where both physician and other qualified health
split visit? care professional perform face-to-face and non-face-
to-face work related to the visit. Only distinct time from
Keywords/Questions Notes (Right Column)

each individual is counted (e.g., if two professionals meet

the patient together, only one person's time is counted).

If the total time exceeds the typical time for an E/M code,
What is prolonged
prolonged service codes can be used in addition to the
time?
primary code.

- Preparing for the encounter (e.g., reviewing tests).

- Reviewing history (separately obtained).
- Medically appropriate examination/evaluation.
What activities are - Counseling/education of the patient/family.
included in time for - Ordering medications/tests/procedures.
E/M services? - Referring/communicating with other professionals (when
not separately reported).
- Documenting clinical information.
- Care coordination.

- Performance of separately reported services.

What is not counted
- Travel time.
in time?
- General teaching not focused on the patient.

Summary (Bottom Section)

Time-based E/M coding is used when time is a significant factor in determining the
level of service. Total time includes both face-to-face and non-face-to-face
activities by the physician or other qualified health care professional on the day of
the encounter. Shared or split visits count only distinct time spent by each
professional. Activities such as preparing for the encounter, examining the
patient, and counseling/educating are counted, while travel time and general
teaching are excluded. Prolonged service codes are used if time exceeds typical
levels.

Unlisted Services & Special Report

Keywords/Questions Notes (Right Column)

What are unlisted services Unlisted services are those not specifically listed
in E/M? in the CPT E/M section.
Use the appropriate unlisted codes, such as:
- 99429 (Unlisted preventive medicine service)
- 99499 (Unlisted evaluation and management
 Keywords/Questions Notes (Right Column)

service).

When a service is not included in the CPT

When do you use an
codebook but is still provided, the unlisted code
unlisted service code?
should be used.

What is required when A Special Report must be included, detailing the

reporting an unlisted service's medical appropriateness and
service? necessity.

- Description of the service and its need.

- Time, effort, and equipment used.
What should the Special - Complexity of symptoms and final diagnosis.
Report include? - Pertinent findings, diagnostic/therapeutic
procedures, and follow-up care.
- Concurrent problems being managed.

To justify the use of an unlisted code and

Why is a Special Report
demonstrate the necessity and appropriateness
needed?
of the service.

Summary (Bottom Section)

Unlisted services are used when an E/M service is not listed in the CPT
codebook, and special codes like 99429 (preventive medicine) or 99499
(evaluation and management) are used. A Special Report must accompany the
unlisted code to explain the nature, necessity, and medical appropriateness of
the service. The report should include details such as time, effort, diagnosis,
procedures, and follow-up care, to justify why the service cannot be reported under
standard codes.

E/M: Office & Hospital Observation Services

Keywords/Questions Notes (Right Column)

- 99217 (Observation Care Discharge) deleted →

Use 99238, 99239.
What changes were made to - 99218-99220 (Initial Observation Care)
observation care codes? deleted → Use 99221-99223.
- 99224-99226 (Subsequent Observation Care)
deleted → Use 99231-99233.

How are inpatient & - Same codes (99221-99223, 99231-99233)

observation services apply to both inpatient and observation
 Keywords/Questions Notes (Right Column)

patients.
reported? - These codes also apply to partial
hospitalization services.

No, "observation status" patients do not

Is a specific hospital have to be in a designated observation unit.
observation unit required? They may be placed anywhere in the hospital
(e.g., ED, general floor).

How do you code if a patient

Use 99234, 99235, or 99236, depending on the
is admitted & discharged on
level of service.
the same day?

How is total time calculated - Total time is counted by calendar date.

for encounters that span two - If care continues past midnight, all time is
calendar dates? counted on one reported date.

Summary (Bottom Section)

Observation care codes 99217-99226 were deleted, and hospital inpatient
codes (99221-99223, 99231-99233) now apply to both inpatient &
observation patients. These codes also cover partial hospitalization.
Observation status patients do not need to be in a specific unit, and if a
patient is admitted and discharged the same day, use 99234-99236. Total
time is counted by calendar date, but if a service continues past midnight, the
entire duration is reported under one date.

Initial Hospital Inpatient or Observation Care

Keywords/Questions Notes (Right Column)

When can an initial hospital When the patient has not received professional
inpatient or observation services from the same specialty/subspecialty
care code be reported? provider in the same group during the stay.

They are considered to be in the same

How are APNs and PAs
specialty/subspecialty as the physician they work
classified?
with.

What code is used for

99477 (Neonatal critical care for infants ≤28 days
neonates needing intensive
old).
care?

Can services at another Yes. If a patient is admitted from another site

 Keywords/Questions Notes (Right Column)

site be reported separately (e.g., ED, office, nursing facility), the initial site
if the patient is later service can be separately reported with
admitted? Modifier 25 if significant & separately identifiable.

- If a consultant evaluates a patient before

admission and then sees them again after
How are consultation admission, they report subsequent inpatient
services handled if a codes (99231-99233), not initial codes.
patient is later admitted? - If a consultation was provided in an outpatient
setting before admission, the inpatient visit is still
reported as subsequent care.

What codes are used if a

patient is admitted &
99234, 99235, 99236, depending on MDM or time.
discharged on the same
day?

Does transitioning from No, transitioning from observation to inpatient is

observation to inpatient considered part of the same stay for coding
start a new stay? purposes.

- 99221: 40+ minutes (Straightforward/Low MDM).

What are the time-based
- 99222: 55+ minutes (Moderate MDM).
criteria for 99221-99223?
- 99223: 75+ minutes (High MDM).

What code is used for

services exceeding 90 Prolonged services code 993X0.
minutes?

Summary (Bottom Section)

Initial inpatient or observation care codes (99221-99223) are used for the
first encounter with a patient during a hospital or observation stay, unless they
were already seen by the same provider group/specialty. If the patient
transitions from observation to inpatient, it is still considered the same stay.
If admitted & discharged the same day, use 99234-99236. Consultations
before admission are coded as subsequent inpatient care (99231-99233).
Time-based selection applies, with 99221 requiring 40+ minutes, 99222
requiring 55+ minutes, and 99223 requiring 75+ minutes. For prolonged
services (90+ minutes), use 993X0.
Subsequent Hospital Inpatient or Observation
Care
Keywords/Questions Notes (Right Column)

What are subsequent hospital - Used for follow-up visits after the initial
inpatient or observation care inpatient or observation care.
codes? - Includes 99231, 99232, and 99233.

- Based on Medical Decision Making

How is level selection
(MDM) or total time spent on the date of
determined?
service.

- 99231: Straightforward/Low MDM, 25+

What are the MDM & time minutes.
requirements for each code? - 99232: Moderate MDM, 35+ minutes.
- 99233: High MDM, 50+ minutes.

What code is used for prolonged

993X0 (Prolonged services code).
services beyond 65 minutes?

Summary (Bottom Section)

Subsequent hospital inpatient or observation care codes (99231-99233)
are used for follow-up visits during an inpatient or observation stay. The level is
determined by MDM or total time:
 99231 (Straightforward/Low MDM) requires 25+ minutes.
 99232 (Moderate MDM) requires 35+ minutes.
 99233 (High MDM) requires 50+ minutes.
For visits exceeding 65 minutes, prolonged services code 993X0 is used.

Hospital Inpatient or Observation Care (Same-

Day Admission & Discharge)
Keywords/Questions Notes (Right Column)

When a patient is admitted & discharged on

the same date, requiring at least two
When are 99234-99236 used?
encounters (one for admission, one for
discharge).

Which codes apply if Use 99221-99223 (Initial) and 99231-99233

 Keywords/Questions Notes (Right Column)

admission & discharge occur (Subsequent), with 99238-99239 (Discharge

on different dates? Services).

What if the patient is

admitted & discharged in a Use 99221-99223, not 99234-99236.
single encounter?

Can 99238 or 99239 be

No, do not report 99238/99239 with 99221-
reported with 99221-99223
99223 for same-day services.
for same-day discharge?

What code is used for

newborn admission & 99463.
discharge on the same date?

How is level selection By Medical Decision Making (MDM) or total

determined? time spent on the date of service.

- 99234: Straightforward/Low MDM, 45+

What are the MDM & time
minutes.
requirements for 99234-
- 99235: Moderate MDM, 70+ minutes.
99236?
- 99236: High MDM, 85+ minutes.

What code is used for services

993X0 (Prolonged services code).
exceeding 100 minutes?

Summary (Bottom Section)

Codes 99234-99236 are used for patients admitted & discharged on the
same date, requiring at least two encounters (one for admission & one for
discharge). If admission & discharge happen in one encounter, use 99221-
99223 instead. Discharge codes (99238/99239) should not be reported
separately when using 99221-99223. Time-based coding is allowed, with
99234 requiring 45+ minutes, 99235 requiring 70+ minutes, and 99236
requiring 85+ minutes. For services exceeding 100 minutes, use prolonged
services code 993X0.

Hospital Inpatient or Observation Discharge

Services
Keywords/Questions Notes (Right Column)

What do hospital inpatient or These codes report total time spent on the
observation discharge codes date of discharge for final hospital or
 Keywords/Questions Notes (Right Column)

report? observation discharge.

Does discharge time need to be No, time does not have to be continuous,
continuous? but it must be all on the same date.

- Final examination of the patient.

- Discussion of hospital stay.
What services are included in - Instructions for continuing care (to
discharge codes? caregivers).
- Preparation of discharge records,
prescriptions, referrals.

Which codes are used for

99234-99236 are used if the admission &
admission & discharge on the
discharge occur on the same date.
same date?

Which providers use 99238 & Only the physician or QHP responsible for
99239? discharge services reports these codes.

Other physicians/QHPs providing instructions

How do other providers report
or post-discharge coordination use
discharge-related services?
99231-99233 instead.

What are the time-based

- 99238: 30 minutes or less.
requirements for discharge
- 99239: More than 30 minutes.
codes?

What code is used for newborn

admission & discharge on the 99463.
same day?

Summary (Bottom Section)

Hospital inpatient or observation discharge codes (99238 & 99239) report
final discharge services on the last day of hospitalization or observation.
The total time on that date is counted, even if it is not continuous. 99238 is
used for 30 minutes or less, while 99239 is for more than 30 minutes. Only
the physician/QHP responsible for discharge reports these codes, while other
providers use 99231-99233 if involved in post-discharge planning. If the
admission & discharge occur on the same day, use 99234-99236 instead.
 Consultations
Keywords/Questions Notes (Right Column)

A type of evaluation & management (E/M)

service performed at the request of another
What is a consultation? physician, QHP, or appropriate source to
recommend care for a specific condition or
problem.

Can a consultant perform Yes, the consultant may initiate diagnostic

diagnostic/therapeutic and/or therapeutic services at the same or
services? subsequent visit.

What if a patient or family

This is not considered a consultation and
requests a consultation
should not be coded with consultation codes.
without a physician referral?

What must a consultant A written report detailing the consultant’s

provide to the requesting opinion and any services ordered or
provider? performed.

Use Modifier 32 when the consultation is

How is a mandated
required by a third party (e.g., insurance,
consultation reported?
government program).

- If a patient is admitted to a hospital,

How are admissions observation, or nursing facility after a
resulting from consultations consultation, report the service using initial care
reported? codes (99221-99223, 99304-99306) instead of
consultation codes.

Summary (Bottom Section)

Consultation services are requested by another provider or appropriate
source and involve evaluating a specific problem and providing
recommendations. The consultant can initiate diagnostic/therapeutic
services but must provide a written report to the requesting provider.
Consultations requested directly by a patient or family are not coded as
consultations. If a third-party mandates a consultation, Modifier 32 should
be used. If a consultation results in a hospital or nursing facility admission,
use initial care codes instead of consultation codes.
 Office or Other Outpatient Consultations
Keywords/Questions Notes (Right Column)

- Office
Where can outpatient - Other outpatient site
consultations take place? - Home or residence
- Emergency department

- Office visits (99212-99215) for follow-ups

What codes are used for follow- in the office.
up visits after a consultation? - Home/residence visits (99347-99350) for
follow-ups at home.

What if the consultant takes - If the consultant assumes ongoing care,

over care instead of just giving use new or established patient visit codes
an opinion? instead of consultation codes.

What happened to 99241? Deleted → Use 99242 instead.

What code is used for

prolonged outpatient 99417 (For services 70+ minutes).
consultations?

- 99242: Straightforward MDM, 20+ minutes.

What are the MDM & time
- 99243: Low MDM, 30+ minutes.
requirements for outpatient
- 99244: Moderate MDM, 40+ minutes.
consults?
- 99245: High MDM, 55+ minutes.

Summary (Bottom Section)

Outpatient consultation codes 99242-99245 are used for consultations in the
office, home, or emergency department. Follow-up visits are reported using
regular office or home visit codes (not consultation codes). If the consultant
takes over care, use the appropriate new or established patient visit codes
instead. 99241 was deleted, and prolonged services beyond 70 minutes
should be coded with 99417. Time-based selection is allowed, with 99242
requiring 20+ minutes, 99243 requiring 30+ minutes, 99244 requiring 40+
minutes, and 99245 requiring 55+ minutes.

Inpatient or Observation Consultations

Keywords/Questions Notes (Right Column)

Where are inpatient or - Hospital inpatients

observation consultation - Observation-level patients
 Keywords/Questions Notes (Right Column)

- Nursing facility residents

codes used?
- Partial hospital settings

- If the patient has not received face-to-face

services from the same specialty/subspecialty
When can a consultation
provider in the same group during the stay.
be reported?
- Only one consultation per admission can be
reported.

- Use 99231-99233 for subsequent

How are follow-up visits inpatient/observation visits.
after a consultation coded? - Use 99307-99310 for subsequent nursing
facility visits.

What happened to 99251? Deleted → Use 99252 instead.

What code is used for

prolonged inpatient 993X0 (For services 95+ minutes).
consultations?

- 99252: Straightforward MDM, 35+ minutes.

What are the MDM & time
- 99253: Low MDM, 45+ minutes.
requirements for inpatient
- 99254: Moderate MDM, 60+ minutes.
consults?
- 99255: High MDM, 80+ minutes.

Summary (Bottom Section)

Inpatient or observation consultations (99252-99255) are used for hospital,
observation, or nursing facility consults. A consultation can only be
reported once per admission, and subsequent visits should use follow-up
care codes (99231-99233 or 99307-99310). 99251 was deleted, and
prolonged consults exceeding 95 minutes should be coded with 993X0.
Time-based selection is allowed, with 99252 requiring 35+ minutes, 99253
requiring 45+ minutes, 99254 requiring 60+ minutes, and 99255 requiring
80+ minutes.

Emergency Department Services

Keywords/Questions Notes (Right Column)

Are ED visits classified as No distinction is made between new and

new or established patient established patients in the ED. All patients are
 Keywords/Questions Notes (Right Column)

visits? coded the same.

How is an emergency A hospital-based facility providing unscheduled

department (ED) defined? episodic services available 24/7.

Yes. Critical care (99291, 99292) can be

Can critical care services
reported if the patient’s condition changes after
be reported in the ED?
an ED visit and requires critical care.

Use 99221-99223 for initial observation

encounters.
How are patients in
Use 99231-99233, 99238-99239 for
observation status coded?
subsequent/discharge observation
encounters.

How are admission &

discharge on the same date Use 99234-99236.
coded?

What codes are used for Procedures with their own CPT codes should be
separate procedures in the reported separately, using appropriate modifiers if
ED? needed.

What if a patient is seen in

Use office/outpatient visit codes (99202-
the ED for provider
99215) instead of ED codes.
convenience?

No, time is not a descriptive component for ED

Is time a factor in ED E/M
visits because care is variable and often involves
coding?
multiple encounters over time.

- 99281: May not require physician presence.

- 99282: Straightforward MDM.
What are the levels of ED
- 99283: Low MDM.
visits?
- 99284: Moderate MDM.
- 99285: High MDM.

Direction of EMS emergency care by a hospital-

What is 99288 used for? based physician/QHP in two-way communication
with ambulance personnel.

Summary (Bottom Section)

ED services do not distinguish between new and established patients. The
facility must be hospital-based and open 24/7. Critical care codes (99291-
99292) can be reported if the patient’s condition worsens after an ED visit.
Observation status patients follow initial, subsequent, or discharge codes
(99221-99223, 99231-99233, 99238-99239). If admission & discharge occur on
the same date, use 99234-99236. Time is not a factor in ED E/M coding.
Procedures should be reported separately with modifiers as needed.
99288 is used for hospital-based EMS direction.

Nursing Facility Services

Keywords/Questions Notes (Right Column)

- Skilled nursing facilities (SNFs)

- Nursing facilities (NFs)
What types of facilities use
- Psychiatric residential treatment centers
nursing facility codes?
- Immediate care facilities for individuals
with intellectual disabilities

- Principal/admitting physician (oversees

Who can report nursing overall care)
facility services? - Other physicians or QHPs providing
specialty care

High MDM for initial care includes multiple

How is Medical Decision
morbidities requiring intensive management,
Making (MDM) determined
frequent medication/treatment changes, and
for initial care?
risk of hospital readmission.

What are the two - Initial Nursing Facility Care (99304-99306)

subcategories of nursing - Subsequent Nursing Facility Care (99307-
facility services? 99310)

Can services at another site Yes. If a patient is seen in another setting (e.g.,
be reported separately ED, office) before admission, those services can
before nursing facility be reported separately using Modifier 25 if
admission? significantly separate.

How are hospital discharge

and nursing facility Use 99238-99239 for hospital discharge and
admission on the same date 99304-99306 for initial nursing facility care.
coded?

How often can initial nursing

Only once per admission per provider,
facility care codes be
regardless of the length of stay.
reported?
 Keywords/Questions Notes (Right Column)

Who must perform the initial A physician (MD/DO) only—QHPs (e.g., NPs,
comprehensive visit in a PAs) can perform it for nursing facility
skilled nursing facility (SNF)? patients only if state law allows.

- 99304: Straightforward/Low MDM, 25+ minutes

What are the time-based
requirements for initial
- 99305: Moderate MDM, 35+ minutes
nursing facility care codes?
- 99306: High MDM, 45+ minutes

- 99307: Straightforward MDM, 10+ minutes

What are the time-based
- 99308: Low MDM, 15+ minutes
requirements for subsequent
- 99309: Moderate MDM, 30+ minutes
nursing facility care codes?
- 99310: High MDM, 45+ minutes

What code is used for

prolonged nursing facility 993X0 (For services 60+ minutes).
services?

What codes are used for - 99315: 30 minutes or less

nursing facility discharge? - 99316: More than 30 minutes

- New patient codes (99324-99328) were

deleted → Use home/residence services
(99341-99345).
What happened to - Established patient codes (99334-99337)
domiciliary, rest home, or were deleted → Use home/residence services
custodial care codes? (99347-99350).
- Care plan oversight codes (99339-99340)
were deleted → Use care management codes
(99437, 99491, 99424, 99425).

Summary (Bottom Section)

Nursing facility services (99304-99316) cover evaluation, management,
and discharge services for patients in SNFs, nursing facilities, psychiatric
treatment centers, and intellectual disability care facilities. Initial care
codes (99304-99306) are reported once per admission, and subsequent
care codes (99307-99310) are used for follow-up visits. Hospital discharge
and nursing facility admission can be reported separately. Physicians must
perform initial comprehensive SNF visits, while QHPs may do so in nursing
facilities if state law allows. Prolonged services (60+ minutes) use 993X0.
Domiciliary and custodial care codes were deleted and replaced with
home/residence service codes.
 Home or Residence Services & Prolonged
Services
Keywords/Questions Notes (Right Column)

Home includes private residences, temporary

lodging (e.g., hotels), or assisted living facilities.
What defines home or
These services can be provided in a group home,
residence services?
custodial care facility, or residential substance
abuse facility.

Time is used to select the level of service, but travel

What are the key
time is not counted.
guidelines for reporting
Place of service codes should specify the facility
home visits?
type.

- 99341: Straightforward MDM, 15+ minutes

What are the new patient - 99342: Low MDM, 30+ minutes
home service codes? - 99344: Moderate MDM, 60+ minutes
- 99345: High MDM, 75+ minutes

- 99347: Straightforward MDM, 20+ minutes

What are the established
- 99348: Low MDM, 30+ minutes
patient home service
- 99349: Moderate MDM, 40+ minutes
codes?
- 99350: High MDM, 60+ minutes

What happened to
Deleted—use home or residence services codes
domiciliary, rest home,
instead (e.g., 99341-99345, 99347-99350).
and custodial care codes?

What codes are used for

prolonged services in - 99417 (for 90+ minutes of service).
home/residence settings?

What codes are used for - 99358: First hour of prolonged service
prolonged services with before/after direct patient care.
direct patient contact? - 99359: Additional 30 minutes beyond the first hour.

- Less than 30 minutes: Do not report

separately.
- 30-74 minutes: Use 99358 (1st hour) and 99359
What is the rule for time-
(additional).
based reporting of
- 75-104 minutes: Use 99358 (1st hour) and
prolonged services?
99359 x2.
- 105 minutes or more: Use 99358 (1st hour) and
99359 x3 or more.
Summary (Bottom Section)
Home or residence services are reported for patients in homes, assisted
living, group homes, or custodial care facilities. Codes 99341-99345 are used
for new patient home services (time-based selection), and 99347-99350 for
established patients. Prolonged services are reported using 99358 (for the
first hour) and 99359 (for each additional 30 minutes) for direct patient contact.
Domiciliary, rest home, and custodial care services codes were deleted and
replaced with home or residence services codes. Prolonged services codes
can also be used for non-face-to-face activities like record review with 99358
and 99359.

Prolonged Clinical Staff Services & Prolonged

Services
Keywords/Questions Notes (Right Column)

- 99415: First hour of prolonged clinical staff

service (with physician supervision) in the
What are prolonged clinical
office or outpatient setting.
staff services codes?
- 99416: Additional 30 minutes of prolonged
service beyond the first hour.

The physician or other qualified healthcare

What does the physician
professional must provide direct supervision
supervision requirement for
of the clinical staff performing the prolonged
99415/99416 mean?
services.

Time should be based on the total face-to-face

time spent with the patient and/or family, even
How is prolonged clinical staff
if the time is not continuous.
time calculated?
Time spent on separately reported services
(other than E/M) is not counted.

- 99415: First hour of prolonged clinical staff

service, use once per date.
What time requirements exist - 99416: Each additional 30 minutes, use for
for 99415/99416? increments of 30 minutes.
Prolonged service of less than 15 minutes
beyond the first hour is not reported.

Yes, but only one patient's time can be

Can multiple patients be
reported for each encounter, even if multiple
reported for 99415/99416?
patients are seen simultaneously.

What codes report prolonged Use 99417 for physician-provided prolonged

services provided by the services in the outpatient setting (with or
 Keywords/Questions Notes (Right Column)

without direct patient contact).

physician?
Use 993X0 for inpatient or observation care.

Can 99415/99416 be reported No, do not report 99415/99416 in conjunction

with 99417? with 99417.

99417 is used when total time for the

outpatient E/M service (including time with
When is 99417 used? and without direct patient contact) exceeds the
required time for the highest-level service by
15+ minutes.

- For new patient (99205): Time beyond 75

What are the reporting minutes.
requirements for prolonged - For established patient (99215): Time
services in outpatient settings beyond 55 minutes.
(using 99417)? - For consultation services (99245): Time
beyond 70 minutes.

What if prolonged services Use 99417 in 15-minute increments for each

last more than 15 minutes additional 15 minutes beyond the required
beyond the required time? time.

Summary (Bottom Section)

Prolonged clinical staff services are reported using 99415 (for the first hour)
and 99416 (for each additional 30 minutes) of clinical staff time with
physician supervision. These services are in addition to the standard E/M
codes. Time spent on separately reported services does not count toward
prolonged services time. 99417 is used for prolonged services by the physician
and cannot be reported with 99415/99416. For outpatient services,
prolonged service is reported once the time exceeds the required time for the
highest-level E/M service by 15 minutes or more. Do not report for less than 15
minutes of prolonged time beyond the required duration.