E/M Coding for Office or Other Outpatient Services (99201-99215)

Evaluation and management (E/M) coding is a high-volume area of CPT® medical coding, meaning that healthcare providers report E/M codes frequently on medical claims. The codes apply to services that a wide range of primary care and specialty providers perform on a regular basis. Some of the most commonly reported E/M codes are 99201-99215, which represent office or other outpatient visits.

Currently, the E/M codes for office and outpatient visits include patient history, clinical examination, and medical decision-making as the key components for determining the correct code level, and that is the version of the codes that this article focuses on. Anyone interested in E/M coding should be aware that both the American Medical Association (AMA), which maintains the CPT® code set, and the Centers for Medicare & Medicaid Services (CMS) have announced plans for major changes to office/outpatient E/M coding and documentation requirements in 2021. Once those changes are implemented, much of the information below, particularly the material related to key components, will no longer apply to office/outpatient E/M coding.

When to Use New and Established Patient E/M Codes

An important concept for proper use of office/outpatient E/M codes 99201-99215 is that CPT^® divides the codes based on whether the encounter is for a new patient or an established patient.

Codes 99201-99205 apply to new patient visits. The descriptors for all 5 of the codes (99201, 99202, 99203, 99204, and 99205) begin with the same language, including a reference to a new patient: Office or other outpatient visit for the evaluation and management of a new patient ….

Similarly, the descriptors for the established-patient codes (99211, 99212, 99213, 99214, and 99215) share a common beginning that refers to an established patient: Office or other outpatient visit for the evaluation and management of an established patient ….

To determine whether you should choose from new patient codes 99201-99205 or established patient codes 99211-99215, you need to know CPT^®’s definition of new and established patients for E/M purposes. In short, a patient is established if the same provider, or any provider of the same specialty and subspecialty who belongs to the same group practice, has seen that patient for a face-to-face service within the past 36 months. Patients who don’t meet that definition are new patients.

For instance, consider this example of an established patient seeing a physician in an office for an E/M service. A patient saw a neurosurgeon for a face-to-face visit 26 months ago. The patient presents to the office now to see the same neurosurgeon for symptoms of lower back pain. Because the neurosurgeon provided a face-to-face service to the patient within the past 3 years, the neurosurgeon should consider this patient to be established when reporting the current E/M for lower back pain.

One final factor to consider regarding new and established patient definitions is that third-party payers may have their own rules. As an example, Medicare refers to providers of the same specialty in its definition of new and established patients, but there is no reference to subspecialty. This is in line with Medicare’s rule that “physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician,” which you can find in Medicare Claims Processing Manual, Chapter 12, Section 30.6.5.

New Patient E/M: 3 of 3 Key Components

To report an office or other outpatient visit for a new patient, you will choose from E/M codes 99201-99205. As this article mentioned previously, office/outpatient visits include history, clinical examination, and medical decision-making (MDM) as the 3 key components for code selection. To determine which E/M code from 99201-99205 is appropriate for a specific encounter, you must check the stated levels for the key components in each descriptor. A new patient visit must meet the levels listed for all 3 key components to qualify for a given code level.

Reviewing the sample E/M code descriptor below will help make those instructions about key components clearer. The areas specific to the key components are shown in bold text for emphasis.

99203

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

As you can see above, the code descriptor specifies the levels of history, exam, and MDM required for the particular code. The key component levels necessary for each code in the range vary. Table 1 shows the key component requirements for each code from 99201-99205.

Because you must meet (or exceed) the requirements for all 3 key components, the lowest level key component for the visit will determine which new patient E/M code is appropriate. As an example, suppose the physician sees a new patient for an office visit. The physician documents a comprehensive history and exam, and MDM of low complexity. The history and exam levels in the example visit match the requirements listed for 99204 and 99205, but the lowest level key component (in this case, the low complexity MDM) determines the correct E/M code. As a result, you should select 99203 for this visit because the code meets the MDM requirement and exceeds the history and exam requirements.

Established Patient E/M: 2 of 3 Key Components

You have just seen that a new patient E/M visit in the office/outpatient setting must meet the levels for all 3 key components listed in a descriptor to qualify for that code. In contrast, the office/outpatient E/M codes for an established patient, 99212-99215, require a visit to meet only 2 of the 3 key components listed to support the service level. Code 99211 does not reference the 3 key components in its descriptor, and you will learn more about that code later in this article.

Table 2 shows the key component requirements for the different established patient office/outpatient E/M code levels.

To understand the role of key components for an established patient visit in the outpatient setting, consider this example: A provider documents a problem focused history, expanded problem focused exam, and low complexity MDM. In this case, your best choice is level-3 code 99213 (bold added for emphasis):

99213

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.

Although the problem focused history meets the requirement listed for 99212, both the exam and MDM levels support 99213. Because you need to meet the requirements for only 2 of 3 key components when selecting an established outpatient E/M service, 99213 is correct.

Confirm Clinical Indications for 99211

Code 99211 differs from the other office visit codes in that it does not require the 3 key components. In addition, the code descriptor specifies that the visit may not require the presence of a physician or other qualified healthcare professional:

99211

Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

You may hear 99211 unofficially referred to as a nurse visit code because a nurse can perform the service without the billing provider present in the room, and face-to-face visits with physicians and nonphysician practitioners tend to meet the standards for higher level E/M codes. But 99211 can apply to brief but medically necessary visits with a physician or a nonphysician practitioner, such as a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife.

An example of appropriate use of 99211 may involve blood pressure monitoring for a hypertensive patient under a physician’s plan of care, as long as there is established medical necessity for the blood pressure check.

For instance, suppose a physician examines a 65-year-old female patient and finds that her blood pressure is high. He decides to put her on medication to treat the problem. He notes in the chart the patient should return in 2 weeks to see the nurse for a follow-up visit that includes a blood pressure check, an evaluation of how the new blood pressure medicine is working, and a review of any symptoms the patient has had since starting the new medication. In this case, documentation may support reporting 99211 for the low-level visit to the nurse.

As the example emphasizes, the documentation should show clinical indications prompted the intervention to support using 99211. If a stable patient comes in to have her blood pressure checked by the nurse just because the patient wants to know the reading, the visit probably won’t merit use of 99211.

Coding E/M Based on Time

Selecting an office/outpatient E/M code based on the key components is not the only option available. CPT^® and Medicare guidelines also allow you to select from these E/M codes based on time.

This approach to E/M coding applies only when counseling and/or coordination of care dominate the encounter. The medical record must include the extent of counseling and/or coordination of care and make it clear that more than 50% of the encounter was spent on those services.

To make your code choice, you need to know the intraservice time for the visit, which means face-to-face time for office and other outpatient visits. You then need to compare that time to the typical times listed in the E/M code descriptors. For instance, the descriptor for 99213 states, “Typically, 15 minutes are spent face-to-face with the patient and/or family.” Payer requirements may vary for whether you must meet the time listed or are allowed to round up from the midway point to determine the final code choice.

Reporting Multiple Same-Day E/Ms

In some cases, a provider may perform more than 1 office or outpatient E/M service for a patient on the same day. New patient E/M codes 99201-99205 and established patient E/M codes 99211-99215 don’t state “per day” in their descriptors, but payer rules may prevent you from reporting more than 1 E/M code for a single patient on the same date of service.

For instance, Medicare will “not pay 2 E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day,” according to Medicare Claims Processing Manual, Chapter 12, Section 30.6.7.B.

There is an exception to Medicare’s rule about reporting multiple office and outpatient E/M services on the same date, though. If the provider documents that the visits were for unrelated problems and the services could not be provided during the same encounter, then Medicare allows you to report separate E/M codes for the same date. The example the Medicare manual provides is a patient presenting for blood pressure medication evaluation and then returning 5 hours later for evaluation of leg pain following an accident.

To support reporting the services separately, experts advise maintaining distinct documentation for each service. You also will need to check payer preference for which modifier to append to the additional E/M code, such as modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service or modifier 59 Distinct procedural service.

If a provider sees the patient twice on the same day for related problems, and the payer doesn’t allow you to report those services separately, then you should combine the work performed for the 2 visits, and select a single E/ M service code that best describes the combined service. For example, if a patient comes in with elevated blood pressure, the physician may give the patient medication and then have her come back later that day to see how she is doing. In this case, because the visits are for the same complaint, you should combine the work performed for the 2 visits into a single E/M code.

E/M on Same Day as Minor or XXX Procedure

The rules related to reporting 99201-99215 on the same date as a minor procedure are confusing for many coders. You need to understand which services the payer considers separately reportable.

A minor surgical procedure is a procedure with a global period of 0 days or 10 days on the Medicare Physician Fee Schedule (MPFS). Many payers other than Medicare use this definition, as well. The global period refers to the length of time the global surgical package applies.

The basic idea of the global surgical package is that services normally performed by a provider before, during, and after a procedure are included in the surgery code instead of being reported separately. All those usual services get factored into the payment rate for the surgical code, so reporting those usual services separately would result in being paid twice for the same service. Payers scrutinize this area of coding to ensure they aren’t overpaying.

Medicare’s definitions of the 0-day and 10-day global periods, available in the MPFS relative value files,  indicate that Medicare usually does not pay for E/M services during the global period (bold added for emphasis):

• 0-day global period: “Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.”
• 10-day global period: “Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10 day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during the 10-day postoperative period generally not payable.”

One reasons E/M codes during the global period are “generally not payable” is that Medicare considers a decision to perform a minor surgery made immediately before the procedure to be a routine preoperative service, according to Medicare Claims Processing Manual, Chapter 12, Section 40.2.A.4. Additionally, a certain amount of history-taking and physical exam work, as well as follow-up care, is expected for a minor procedure, so the surgical code includes payment for that work.

But the phrase “generally not payable” in the global period definitions leaves room for reporting E/M codes separately under certain circumstances. The rule is that you may report significant, separately identifiable E/M services on the same day as a minor procedure. Medicare provides the example of reporting an E/M code for a full neurological examination on the same date that you report a code for suturing a scalp wound for a patient with head trauma. But you need to ensure documentation supports reporting a distinct E/M service. “Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status,” states Medicare Claims Processing Manual, Chapter 12, Section 40.1.C.

If documentation does support reporting an E/M code on the same date as a minor procedure code, you should append modifier 25 to the E/M service code to acknowledge that special circumstances make the code reportable.

The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 1, states that providers also may submit a distinct E/M code with modifier 25 on the same date as a code that has an XXX global indicator. The XXX indicator means the global concept does not apply to the code.

Again, for you to report the E/M separately, it must be distinct from the typical pre-, intra-, and post-procedure work for the XXX-global code. That means you should not report an E/M for the physician’s supervision of someone else performing the procedure or interpretation of the result of the procedure.

Note that both Medicare and CPT^® state that you do not need different diagnoses for the distinct E/M service and the procedure. But experts advise that separate diagnoses may help show that the E/M was significant and separately identifiable from the surgery. You should not report separate diagnoses simply to improve your chances for payment, however. Always base your ICD-10-CM coding choices on the documentation and follow proper coding rules.

E/M Coding for Decision for Major Surgery

If a physician performs an E/M service on the same date as a major procedure or on the day before the procedure, you may report the E/M separately if the E/M resulted in the decision for surgery. You should append modifier 57 Decision for surgery to the E/M service code in this case.

A major procedure is 1 with a 90-day global period on the MPFS. The definition of a 90-day global period is “Major surgery with a 1-day preoperative period and 90-day postoperative period included in the fee schedule amount.”

As an example of proper modifier 57 use, suppose a surgeon sees a patient with extreme pain in the lower abdomen. The surgeon quickly determines that the patient’s appendix has burst and schedules immediate surgery. In this case, both the E/M service and the surgery are billable because the E/M service resulted in the decision to perform the surgery (In other words, the surgery was not previously planned at the time of the evaluation.). You should append modifier 57 to the E/M code.

Medical Necessity Drives E/M Code Choice

No discussion of E/M coding would be complete without mentioning medical necessity. In all cases, whether a visit involves a new or established patient, medical necessity should determine the extent of the service provided, including elements like the history, exam, and MDM. Consequently, medical necessity determines the final E/M code choice.

In the words of Medicare Claims Processing Manual, Chapter 12, Section 30.6.1, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT^® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”

Proper Use of Office/Outpatient E/M Code 99211

Evaluation and management (E/M) code 99211 is the lowest level established patient E/M code in the range for office or other outpatient visits. This level of service does not require the presence of a physician, which can lead practices to underestimate the importance of complying with reporting rules for this code. But because 99211 is an E/M code, it requires elements of evaluation and management to be performed and documented.

This quick guide offers tips on the dos and don’ts of 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

Support 99211 by Doing These 5 Things

When considering whether to assign 99211 for a service, remember these important points for proper reporting.

• Do make sure there is a separate E/M service. Check for a documented evaluation of the patient along with management of the patient’s care. For example, if a nurse only refills the patient’s medications and no other E/M service takes place, you should not report 99211.
• Do ensure the patient is an established patient. Based on the CPT^® code description, you should report 99211 for an established patient , meaning 1 that has been seen by the rendering provider (or provider of same group and specialty/subspecialty) within the past 3 years, in any setting. You cannot report 99211 for a new patient.
  • The established-patient rule also is important because Medicare applies the concept of incident-to services for 99211, meaning a provider previously furnished a direct, personal, professional service to initiate a course of treatment, and the 99211 service being performed is an incidental part of that care plan.
• Do be certain that the supervising provider is in the office suite. Reporting 99211 to certain payers (including Medicare) requires that the supervising provider be in the office suite at the time of the appointment. The billing provider is not required, however, to be in the room or to provide face-to-face services for the patient. The supervising provider doesn’t have to be the one who created the care plan. Medicare Benefit Policy Manual, Chapter 15, Section 60, provides more information about incident-to services.
• Do bill the service under the supervising provider. All incident-to services must be billed under the provider present in the office when services were performed.
• Do prove that the visit is medically necessary. Look for a documented clinical reason that supports the visit and proves it was above the scope of the other services provided that day. In other words, if you’re reporting the E/M code along with another code, make sure the E/M documentation is significant and separately identifiable from the procedure documentation. For example, a nurse may document the reason for the visit, a brief history of the patient’s illness, any exam processes such as weight or temperature, a list of the patient’s medications, and a brief assessment to support the E/M in addition to the other service performed.

3 Areas to Watch to Prevent 99211 Issues

Proper reporting of 99211 also requires you to know the top problem spots for this code so you can avoid them. Beware of these areas:

• Don’t bill 99211 for services that are part of another E/M service performed on the same day. For example, if your nurse measures the patient’s blood pressure and weight prior to a visit with the physician or provides counseling after the physician has seen the patient, you should not use 99211 because those tasks are considered part of the physician’s office visit.
• Don’t report 99211 for telephone calls. There must be face-to-face contact to report 99211. For example, if a nurse returns a patient’s call and gives instructions over the phone, you can’t submit 99211 for reimbursement.
• Don’t underestimate the importance of documentation. Documentation is essential when requesting reimbursement for 99211 visits. The care provider must document details including the reason for the encounter, which may include educational services as well as evaluation of the patient’s condition with management directed by the physician. You also must have documentation to show that the supervising provider was in the office at the time of the visit. Documentation might be a statement indicating that the nurse was working under a physician in the office, a copy of the physician’s schedule that shows the physician was in the office at the time of the nurse visit, or a statement by the physician with signature and date.