Evaluation and Management

(E/M) Services
 Learning
The following is a listing ofoutcomes:
headings that appear within the Evaluation and
Management (E/M) Services of the CPT:

E/M Guidelines Care Plan Oversight

Office or Other Outpatient Services Services
Preventive Medicine
Hospital Observation Services Services
Non-Face-to-Face
Consultations Services
Special Evaluation and Management
Emergency Department Services Services
Newborn Care
Nursing Facility Services
Services
Cognitive Assessment and Care Plan
Domiciliary, Rest Home (eg, Boarding
Home), or Custodial Care Services Services
Care Management
Domiciliary, Rest Home (eg, Assisted Living Services
Psychiatric Collaborative Care Management
Facility), or Home Care Plan Oversight
Services Services
General Behavioral Health Integration Care
Home Services Management
Prolonged Services

Case Management Services

 E/M Summary of Guideline Differences
Guidelines:
Component(s) for Code Selection Office or Other Outpatient Services Other E/M Services (Hospital Observation,
 There are two sets of Hospital Inpatient, Consultations,
Emergency Department, Nursing Facility,
guidelines: Domiciliary, Rest Home, or Custodial Care,
Home)

1. Office or other outpatient

services
2. Remaining E/M services History and Examination •As medically appropriate. Not used in code •Use key components (history, examination,
selection MDM)

 There are sections that are

Medical Decision Making (MDM) •May use MDM or total time on the date of •Use key components (history, examination,
common the encounter MDM)
to both (ie, Guidelines in
Common) Time •May use MDM or total time on the date of •May use face-to-face time or time at the
the encounter bedside and on the patient's floor or unit
when counseling and/or coordination of
 The main differences care dominates the service.
Time is not a descriptive component for the
between the two sets of emergency department levels of E/M
services.
guidelines:

1. Office or other outpatient

services use medical
decision making (MDM) or MDM Elements •Number and complexity of problems •Number of diagnoses or management
addressed at the encounter options
time as the basis for •Amount and/or complexity of data to be •Amount and/or complexity of data to be
reviewed and analyzed reviewed
selecting a code level. •Risk of complications and/or morbidity •Risk of complications and/or morbidity
or or
mortality of patient management mortality
2. The other E/M codes use
history, examination, and
MDM and only use time when
 Classification of Evaluation  Basic format of the levels of E/M
and services:
Management (E/M) Services:  The basic format of the levels of E/M
 The E/M section is divided into broad services is the same for most categories.
1. categories:
Office visits
2. Hospital 1. First, a unique code number is listed.
visits
3. Consultatio 2. Second, the place and/or type of service is
 Most
ns of the categories are further divided specified,
into two or eg, office consultation.
more subcategories of E/M services. 3. Third, the content of the service is
1. Two subcategories of office visits (new defined.
patient and established patient) 4. Fourth, time is
specified.
2. subcategories of hospital visits (initial
and
subsequent).

3. The subcategories of E/M services are

further classified into levels of E/M
services that are identified by specific
codes.
 Guidelines Common to All E/M Services:

 Levels of E/M Services:

1. Three to five levels of E/M services available for reporting purposes

2. Levels of E/M services are not interchangeable among the different categories or subcategories of service.
For example, the first level of E/M services in the subcategory of office visit, new patient, does not have the
same definition as the first level of E/M services in the subcategory of office visit, established patient.

3. Each level of E/M services may be used by all physicians or other qualified health care professionals.

 New and Established Patient:

New Patient: Established Patient:

• A new patient is one who has not received any • An established patient is one who has received
professional services from the physician/qualified professional services from the physician/qualified
health care professional or another health care professional or another
physician/qualified health care professional of physician/qualified health care professional of the
the exact same specialty and subspecialty who exact same specialty and subspecialty who belongs to
belongs to the same group practice, within the the same group practice, within the past three years.
past three years.
3.In the instance where a
physician/qualified health care
professional is on call for or covering
for another physician/qualified health
care professional, the patient’s
encounter will be classified as it
would have been by the
physician/qualified health care
professional who is not available.

4.When advanced practice nurses and

physician assistants are working with
physicians, they are considered as
working in the exact same specialty
and exact same subspecialties as the
physician.

5.No distinction is made between new

and established patients in the
emergency department. E/M services
in the emergency department category
may be reported for any new or
established patient who presents for
treatment in the emergency
department.
 Time:  Shared or Split visit:
1. Time is not a descriptive 1. A visit in which a physician and other
component for the emergency qualified health care professional(s)
department levels of E/M services jointly provide the face-to-face and non-
because emergency department face-to-face work related to the visit.
services are typically provided on a
variable intensity basis, often 2. When time is being used to select the
involving multiple encounters with appropriate level of services for which
several patients over an extended time- based reporting of shared or split
period of time. Therefore, it is visits is allowed, the time personally
often difficult to provide accurate spent by the physician and other
estimates of the time spent face- qualified health care professional(s)
to-face
2. Time with
may bethe patient.
used to select a code assessing and managing the patient on
level in office or other outpatient the date of the encounter is summed to
services whether or not counseling define total time.
and/or coordination of care 3. Only distinct time should be summed for
dominates the service. shared or split visits (ie, when two or
3. Time may only be used for more individuals jointly meet with or
selecting the level of the other discuss the patient, only the time of one
E/M services when counseling individual should be counted).
and/or coordination of care
dominates the service.
 Face-to-face time: (outpatient consultations, domiciliary, rest home, or custodial services, home
services, cognitive assessment and care plan service)

1. For coding purposes, these services is defined as only that time spent face-to-face with the
patient and/or family.

2. This includes the time spent performing such tasks as obtaining a history, examination, and counseling
the patient.
 Total time on the date of the encounter: (office or other outpatient services)

1. For coding purposes, time for these services is the total time on the date of the encounter.

2. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or
other qualified health care 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 activities
normally performed by clinical staff).
o Physician/other qualified health care
professional time includes the
following activities, when
performed:
1. Preparing to see the patient (eg, review
of tests)
2. obtaining and/or reviewing separately
obtained history
3. performing a medically appropriate examination
and/or evaluation
4. counseling and educating the
patient/family/caregiver
5. ordering medications, tests, or procedures
6. referring and communicating with other
health care professionals (when not
separately reported)
7. documenting clinical information in the
electronic or other health record
8. independently interpreting results (not
separately reported) and communicating
results to the patient/family/caregiver
9. care coordination (not separately reported)

o Do not count time spent on the

following:
10. the performance of other services that are
reported separately
11. Travel
 Concurrent  Counseling
1. Care :
Concurrent care is the provision • Counseling is a discussion with a patient and/or family
of similar services (eg, hospital concerning one or more of the following areas:
visits) to the same patient by
more than one physician or
1. Diagnostic results, impressions, and/or recommended
other qualified health care
professional on the same day.
diagnostic studies
2. When concurrent care is
provided, no 2. Prognosis
special reporting is required.
 Transfer of 3. Risks and benefits of management (treatment) options
1. Care:
Transfer of care is the process
whereby a physician or other 4. Instructions for management (treatment) and/or follow-up
qualified health care
professional who is providing
5. Importance of compliance with chosen management
management for some or all of
a patient’s problems
(treatment) options
relinquishes this responsibility
to another physician or other 6. Risk factor reduction
qualified health care
professional who explicitly 7. Patient and family education
agrees to accept this
responsibility and who, from
the initial encounter, is not
providing consultative
services.
 Guidelines for Office or Other Outpatient E/M
Services:
 History and/or Examination
• Office or other outpatient services include a medically appropriate history
and/or physical examination, when performed.

• The nature and extent of the history and/or physical examination are
determined by the treating physician or other qualified health care
professional reporting the service.

• The care team may collect information and the patient or caregiver may supply
information directly (eg, by electronic health record [EHR] portal or
questionnaire) that is reviewed by the reporting physician or other qualified
health care professional.

• The extent of history and physical examination is not an element in selection of

the level of
office or other outpatient codes.
 Number and Complexity of Problems Addressed at the Encounter:
• One element used in selecting the level of office or other outpatient services is the number and complexity of
the problems that are addressed at an encounter.

• Multiple new or established conditions may be addressed at the same time and may affect MDM.

• Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition.

• Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M
services unless they are addressed, and their presence increases the amount and/or complexity of data to
be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient
management.

• The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive
evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly
morbid condition.

• Therefore, presenting symptoms that are likely to represent a highly morbid condition may “drive”
MDM even when the ultimate diagnosis is not highly morbid.

• The evaluation and/or treatment should be consistent with the likely nature of the condition. Multiple
problems of a lower severity may, in the aggregate, create higher risk due to interaction.

• The term “risk” as used in these definitions relates to risk from the condition. While condition risk and
management risk may
often correlate, the risk from the condition is distinct from the risk of the management.
Definitions:

1. MINIMAL: A problem that may not require the presence of the physician or other qualified health care professional,
but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211, 99281).

2. LOW: A problem with an expected duration of at least one year or until the death of the patient. For the purpose of
defining chronicity, conditions are treated as chronic whether or not stage or severity changes (e.g., uncontrolled diabetes
and controlled diabetes are a single chronic condition).

3. MODERATE: A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control
progression and requiring additional supportive care or requiring attention to treatment for side effects.

4. HIGH: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have
significant risk of morbidity and may require escalation in level of care.
 Time:

• For instructions on using time to select the level of office or other outpatient E/M services code, see the Time
subsection in the Guidelines Common to All E/M Services.
 Hospital Observation • Hospital Observation Services
Services: includes three type of service:
• When a patient has a condition that
needs to be monitored to determine 1. Initial Observation Care: Codes
a course of action, he may be are reported only by the physicians
admitted to and other health care professional
“Observation Status”. admitting the patient to
observation status.
• The patient is not required to be in 2. Observation Care Discharge
a specific area of the hospital to be Service: Are used to report the
deemed in observation status. final exam and discharge of the
patient.
• When the patient is seen at another 3. Subsequent Observation Care:
site of services(eg: ED), & Are used when the patient is seen
observation status is initiated at on a day other than the date of
that time of service, all E/M admission or discharge.
services provided by the admitting
physicians are considered part of
the initial observation care and not
reported separately.
 Consultations:
• A consultation is a type of evaluation and management service provided at the request of
another physician or appropriate source to either recommend care for a specific condition or
problem or to determine whether to accept responsibility for ongoing management of the
patient’s entire care or for the care of a specific condition or problem.

• A physician consultant may initiate diagnostic and/or therapeutic services at the same or
subsequent visit.

• A “consultation” initiated by a patient and/or family, and not requested by a physician or

other appropriate source is not reported using the consultation codes but may be reported
using the office visit, home service, or domiciliary/rest home care codes as appropriate.

• The written or verbal request for consult may be made by a physician or other appropriate
source and documented in the patient’s medical record by either the consulting or
requesting physician or appropriate source.

• The consultant’s opinion and any services that were ordered or performed must also be
documented in the patient’s medical record and communicated by written report to the
requesting physician or other appropriate source.

• If a consultation is mandated (eg, by a third-party payer) modifier 32 should also be

reported.

• Any specifically identifiable procedure (ie, identified with a specific CPT code) performed on or
subsequent to the date of the initial consultation should be reported separately.
• If subsequent to the completion of a consultation the consultant assumes responsibility for management
of a portion or all of the patient’s condition(s), the appropriate Evaluation and Management services
code for the site of service should be reported.

• In the hospital or nursing facility setting, the consultant should use the appropriate inpatient
consultation code for the
initial encounter and then subsequent hospital or nursing facility care codes.

• In the office setting, the consultant should use the appropriate office or other outpatient consultation
codes and then the established patient office or other outpatient services codes.
 Office or Other Outpatient Consultations:

1. New or Established Patient:

• The following codes are used to report consultations provided in the office or in an outpatient or other
ambulatory
facility, including hospital observation services, home services, domiciliary, rest home, or emergency
department .

• Follow-up visits in the consultant’s office or other outpatient facility that are initiated by the
consultant or patient are reported using the appropriate codes for established patients, office visits,
domiciliary, rest home, or home.

• If an additional request for an opinion or advice regarding the same or a new problem is received from
another physician or other appropriate source and documented in the medical record, the office
consultation codes may be used again.

• Services that constitute transfer of care (ie, are provided for the management of the patient’s entire care
 Emergency Department Services:

 New or Established Patient:

• The following codes are used to report evaluation and management services
provided in the emergency department.

• No distinction is made between new and established patients in the emergency

department.

• An emergency department is defined as an organized hospital-based facility for

the provision of unscheduled episodic services to patients who present for
immediate medical attention.

• The facility must be available 24 hours a day.

 Time as a Factor in the Emergency Department Setting:

• Time is not a descriptive component for the emergency department levels of E/M
services because emergency department services are typically provided on a
variable intensity basis, often involving multiple encounters with several patients
over an extended period of time.
 Initial Nursing Facility Care:

 New or Established Patient

• When the patient is admitted to the nursing facility in the course of an encounter in
another site of service (eg, hospital emergency department, office), all evaluation
and management services provided by that physician in conjunction with that
admission are considered part of the initial nursing facility care when performed on
the same date as the admission or readmission.

• The nursing facility care level of service reported by the admitting physician
should include the services related to the admission he/she provided in the other
sites of service as well as in the nursing facility setting.

• Hospital discharge or observation discharge services performed on the same

date of nursing facility admission or readmission may be reported separately.

• For a patient discharged from inpatient status on the same date of nursing facility
admission or readmission, the hospital discharge services should be reported with
codes 99238, 99239 as appropriate.

• For a patient discharged from observation status on the same date of nursing
facility admission or
readmission, the observation care discharge services should be reported with code
99217.

• For a patient admitted and discharged from observation or inpatient status on the
 Subsequent Nursing Facility Care:
• All levels of subsequent nursing facility care include
reviewing the medical record and reviewing the results of
diagnostic studies and changes in the patient’s status (ie,
changes in history, physical condition, and response to
management) since the last assessment by the physician or
other qualified health are professional.

 Nursing Facility Discharge Services

• The nursing facility discharge day management codes are to
be used to report the total duration of time spent by a
physician or other qualified health care professional for the
final nursing facility discharge of a patient.

• The codes include, as appropriate, final examination of the

patient, discussion of the nursing facility stay, even if the
time spent on that date is not continuous. Instructions are
given for continuing care to all relevant caregivers, and
preparation of discharge records, prescriptions and referral
forms.
 Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care
Services:
• Domiciliary care refers to care provided in a supervised home setting.

• Assisted living facilities would be considered domiciliary care.

• New patient visit require all three key components to be met to report the chosen service level.

• Established patient visits require two of three key components to be met.

 Domiciliary, Rest Home (e.g. Assisted Living Facility), or

Home Care Plan Oversight Services:

• Indicates that the service provided to patient in certain locations.

• Oversight of patients in a domiciliary, a rest home, or in the patients own home is reported with
codes from this category, based on the providers time within a 30 day period.

 Home Services
• E/M services provided to a patient in a private residence are reported from this category. The
codes distinguish between new and established patient. New patient service require all three key
components to be mt to report the chosen service level; established patient service require two of
three key components.
 Prolonged Services:

 Prolonged Service With Direct Patient Contact (Except with Office or Other
Outpatient Services):

• Codes 99354-99357 are used when a physician or other qualified health care professional
provides prolonged service(s) involving direct patient contact that is provided beyond the
usual service in either the inpatient, observation or outpatient setting, except with office or
other outpatient services.

• Direct patient contact is face-to-face and includes additional non-face-to-face services on the
patient’s floor or unit in the hospital or nursing facility during the same session.

• This service is reported in addition to the primary procedure.

• Appropriate codes should be selected for supplies provided or other procedures performed in
the care of the
patient during this period.
 Time in Prolonged Service With Direct Patient Contact :

• Time spent performing separately reported services other than the E/M or psychotherapy service is
not counted
toward the prolonged services time.

• Code 99354 or 99356 is used to report the first hour of prolonged service on a given date,
depending on the place of service.

• Prolonged service of less than 30 minutes total duration on a given date is not separately reported.

• Code 99355 or 99357 is used to report each additional 30 minutes beyond the first hour, depending
on the place of service.

• Either code may also be used to report the final 15-30 minutes of prolonged service on a given date.
Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the
final 30 minutes is not reported separately.

• For E/M services that require prolonged clinical staff time and may include face-to-face services by
the physician or other qualified health care professional, use 99415, 99416.

• For prolonged total time in addition to office or other outpatient services (ie, 99205, 99215), use
99417.

• The following table illustrates the correct reporting of prolonged physician or other qualified health
care professional service with direct patient contact in the inpatient or observation setting beyond
the usual service time.
 Prolonged Service Without Direct Patient Time in Prolonged Service Without Direct
Contact: Patient Contact:

• Codes 99358 and 99359 are used when a • Code 99358 is used to report the first hour of
prolonged service is provided that is neither face- prolonged service on a given date regardless of
to-face time in the outpatient, inpatient, or the place of service. It should be used only once
observation setting, nor additional unit/floor time per date.
in the hospital or nursing facility setting.
• Prolonged service of less than 30 minutes total
• Codes 99358, 99359 may be used during the same duration
session of an evaluation and management service, on a given date is not separately reported.
except office or other outpatient.
• Code 99359 is used to report each additional
• For prolonged total time in addition to office or 30 minutes beyond the first hour. It may also
other outpatient services on the same date of be used to report the final 15 to 30 minutes
service without direct patient contact, use of prolonged service on a given date.
99417.
• Prolonged service of less than 15 minutes
• This service is to be reported in relation to other beyond the first hour or less than 15 minutes
physician or other qualified health care beyond the final 30 minutes is not reported
professional services, including evaluation and separately.
management services at any level.

• Codes 99358 and 99359 are used to report the total

duration of non-face-to-face time spent by a
physician or other qualified health care
professional on a given date providing prolonged
 Prolonged Clinical Staff Services With Physician or Other Qualified
Health Care Professional Supervision:
• Codes 99415, 99416 are used when a prolonged evaluation and management (E/M)
service is provided in the office or outpatient setting that involves prolonged clinical
staff face-to-face time beyond the highest total time of the E/M service, as stated in the
ranges of time in the code descriptions.

• The physician or qualified health care professional is present to provide direct supervision
of the clinical staff.

• This service is reported in addition to the designated E/M services and any other
services provided at the same session as E/M services.
• Time In Prolonged Clinical Staff Services With Physician or Other Qualified
Health Care Professional Supervision:

• Codes 99415, 99416 are used to report the total duration of face-to-face time spent by
clinical staff on a given date providing prolonged service in the office or other outpatient
setting, even if the time spent by the clinical staff on that date is not continuous.

• Time spent performing separately reported services other than the E/M service is not
counted toward the prolonged services time.

• Code 99415 is used to report the first hour of prolonged clinical staff service on a given
date.

• Code 99415 should be used only once per date, even if the time spent by the
clinical staff is not continuous on that date.
• Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the
clinical staff time involved is included in the E/M codes.

• The highest total time in the time ranges of the code descriptions is used in defining when prolonged services
time begins. For example, prolonged clinical staff services for 99214 begin after 39 minutes, and 99415 is not
reported until at least 69 minutes total face-to-face clinical staff time has been performed. When face-to-face
time is noncontiguous, use only the face-to-face time provided to the patient by the clinical staff.

• Code 99416 is used to report each additional 30 minutes of prolonged clinical staff service beyond the first
hour. Code 99416 may also be used to report the final 15-30 minutes of prolonged service on a given date.
Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30
minutes is not reported separately.

 Prolonged Service With or Without Direct Patient Contact on the Date of an Office or Other
Outpatient Service:
• Code 99417 is used to report prolonged total time (ie, combined time with and without direct patient contact)
provided by the
physician or other qualified health care professional on the date of office or other outpatient services

• Time in Prolonged Service With or Without Direct Patient Contact on the Date of an Office or Other
Outpatient Service:
• Code 99417 is only used when the office or other outpatient service has been selected using time alone as the
basis and only after the minimum time required to report the highest-level service has been exceeded by 15
minutes.

• The listed time ranges for 99205 and 99215 represent the complete range of time for which each code may be
reported.
 Case Management Services:

• It is a process in which a physician or another qualified health care professional is responsible for direct
care of a patient and, additionally, for coordinating, managing access to, initiating, and/or supervising other
health care services needed by the patient.

 Medical Team Conferences:

• It include face-to-face participation by a minimum of three qualified health care professionals from
different specialties or disciplines (each of whom provide direct care to the patient), with or without the
presence of the patient, family member(s), community agencies, surrogate decision maker(s) (eg, legal
guardian), and/or caregiver(s).

• The participants are actively involved in the development, revision, coordination, and implementation of
health care services needed by the patient.

• Reporting participants shall have performed face-to-face evaluations or treatments of the patient,
independent of any team conference, within the previous 60 days.

• Physicians or other qualified health care professionals who may report evaluation and management services
should report their time spent in a team conference with the patient and/or family present using evaluation
and management (E/M) codes (and time as the key controlling factor for code selection when counseling
and/or coordination of care dominates the service).
 Care Plan Oversight  Preventive Medicine Services:
• Services:
Care plan oversight services are • The following codes are used to report the
reported separately from codes for preventive medicine evaluation and management
office/outpatient, hospital, home, of infants, children, adolescents, and adults.
nursing facility or domiciliary, or non-
face-to-face services. • The extent and focus of the services will largely
• The complexity and approximate time of depend on the age of the patient.
the care plan oversight services
provided within a 30-day period • If an abnormality is encountered or a preexisting
determine code selection. Only one problem is addressed in the process of performing
individual may report services for a this preventive medicine evaluation and
given period of time, to reflect the sole management service, and if the problem or
or predominant supervisory role with a abnormality is significant enough to require
particular patient. additional work to perform the key components of a
• These codes should not be reported for problem- oriented evaluation and management
supervision of patients in nursing service, then the appropriate office/outpatient code
facilities or under the care of home should also be reported.
health agencies unless they require
recurrent supervision of therapy. • Modifier 25 should be added to the office/outpatient
code to indicate that a significant, separately
identifiable evaluation and management service was
provided on the same day as the preventive medicine
service.

• The appropriate preventive medicine service is

additionally reported.
 Non-Face-to-Face  Online Digital Evaluation and Management
Services:
Services: • These are patient-initiated services with physicians
 Telephone Services: or other qualified health care professionals (QHPs).
• These are non-face-to-face evaluation
and management (E/M) services • Online digital E/M services require physician or
provided to a patient using the other QHP’s evaluation, assessment, and
telephone by a physician or other management of the patient.
qualified health care professional, who
may report evaluation and • These services are not for the nonevaluative
management services. electronic communication of test results, scheduling
of appointments, or other communication that does
• These codes are used to report not include E/M.
episodes of patient care initiated by
an established patient or guardian of • While the patient’s problem may be new to the
an established patient. physician or other QHP, the patient is an
established patient.
• If the telephone service ends with a
decision to see the patient within 24 • Patients initiate these services through Health
hours or next available urgent visit Insurance Portability and Accountability Act
appointment, the code is not (HIPAA)-compliant secure platforms, such as
reported. electronic health record (EHR) portals, secure email,
or other digital applications, which allow digital
communication with the physician or other QHP.

• If within seven days of the initiation of an online

digital E/M service, a separately reported E/M visit
 Interprofessional Telephone/Internet/Electronic Health Record Consultations:
• An interprofessional telephone/Internet/electronic health record consultation is an
assessment and management service in which a patient’s treating (eg, attending or
primary) physician or other qualified health care professional requests the opinion
and/or treatment advice of a physician with
specific specialty expertise (the consultant) to assist the treating physician or other
qualified health care professional in the diagnosis and/or management of the patient’s
problem without patient face-to-face contact with the consultant.

• The patient for whom the interprofessional telephone/Internet/electronic health record

consultation is requested may be either a new patient to the consultant or an established
patient with a new problem or an exacerbation of an existing problem.

• However, the consultant should not have seen the patient in a face-to-face encounter
within the last 14 days. When the telephone/Internet/electronic health record
consultation leads to a transfer of care or other face-to-face service (eg, a surgery, a
hospital visit, or a scheduled office evaluation of the patient) within the next 14 days or
next available appointment date of the consultant, these codes are not reported.

• Telephone/Internet/electronic health record consultations of less than five minutes

should not be reported.
 Special Evaluation and Management Services:
• The following codes are used to report evaluations performed to establish baseline information prior to life or
disability insurance certificates being issued. This service is performed in the office or other setting, and applies
to both new and established patients. When using these codes, no active management of the problem(s) is
undertaken during the encounter.

 Newborn Care Services:

• The following codes are used to report the services provided to newborns (birth through the first 28 days) in
several different
settings.

• Use of the normal newborn codes is limited to the initial care of the newborn in the first days after birth prior to
home discharge.

• E/M services for the newborn include maternal and/or fetal and newborn history, newborn physical
examination(s), ordering of diagnostic tests and treatments, meetings with the family, and documentation in
the medical record.

• When delivery room attendance services (99464) or delivery room resuscitation services (99465) are required,
report these in
addition to normal newborn services Evaluation and Management codes.

• For E/M services provided to newborns who are other than normal, see codes for hospital inpatient services and
neonatal intensive and critical care services.

• When normal newborn services are provided by the same individual on the same date that the newborn
later becomes ill and receives additional intensive or critical care services, report the appropriate E/M code
 Cognitive Assessment and Care Plan Services:
• Cognitive assessment and care plan services are provided when a comprehensive evaluation of a
new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is
required to establish or confirm a diagnosis, etiology and severity for the condition.

• This service includes a thorough evaluation of medical and psychosocial factors, potentially
contributing to increased morbidity.

 Care Management Services:

• Patient with one or more chronic illness my require coordination of complex chronic care.

• The patients condition must be expected to last at east 1 months or until the death.

• There are three general categories of care management services: chronic care management,
complex chronic
care management, and principal care management.

 Psychiatric Collaborative Care Management Services;

• Psychiatric collaborative care services are provided under the direction of a treating physician
or other qualified health care professional (see definitions below) during a calendar month.

• These services are provided when a patient requires a behavioral health care
assessment; establishing, implementing, revising, or monitoring a care plan; and
provision of brief interventions.
 General Behavioral Health Integration Care Management:
• General behavioral health integration care management services (99484) are reported by
the supervising
physician or other qualified health care professional.

• The services are performed by clinical staff for a patient with a behavioral health (including
substance use) condition that requires care management services (face-to-face or non-face-
to-face) of 20 or more minutes in a calendar month.

• A treatment plan as well as the specified elements of the service description is required.

• The assessment and treatment plan is not required to be comprehensive and the
office/practice is not required to have all the functions of chronic care management .

• Code 99484 may be used in any outpatient setting, as long as the reporting professional
has an ongoing relationship with the patient and clinical staff and as long as the clinical
staff is available for face-to-face services with the patient.
Thank
You