What Are E/M Codes?

Evaluation and management (E/M) coding is the use of CPT^® codes from the range 99202-99499 to represent services provided by a physician or other qualified healthcare professional. As the name E/M indicates, these medical codes apply to visits and services that involve evaluating and managing patient health.

Examples of E/M services include office and outpatient visits, hospital visits, home services, and preventive medicine services. Codes for services like surgeries and radiologic imaging are found outside of the E/M section of the CPT^® code set.

Medicare, Medicaid, and other third-party payers accept E/M codes on claims that physicians and other qualified healthcare professionals submit to request reimbursement for their professional services. Facilities and practices may use E/M codes internally, as well, to assist with tracking and analyzing the services they provide.

E/M services are high-volume services. Even small E/M coding mistakes can cause major compliance and payment issues if the errors are repeated on a large number of claims. To ensure accurate reporting and reimbursement for these services, those involved in the coding process need to stay up to date on E/M coding rules. For example, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) implemented major changes for office/outpatient E/M coding and documentation rules in 2021 and other E/M sections in 2023.

What a Typical E/M Code Looks Like

CPT^® is an abbreviation for Current Procedural Terminology, a set of five-character medical codes maintained by the AMA. Evaluation and Management is one section in the CPT^® code set. Other sections in the CPT^® code set include Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine.

CPT^® includes more than two dozen categories of E/M codes, from office and other outpatient services to behavioral health integration care management. You may find further divisions within each category, such as separate options for new patients and established patients.

The CPT^® code set uses the same basic format to describe the E/M service levels for many (but not all) categories, with the option to choose the code level based on medical decision making (MDM) or total time. This is the typical format for many of the most commonly used E/M codes:

• A unique code, such as 99235

• The place and/or type of service, such as hospital inpatient or observation care with admission and discharge on the same date

• The requirement of a medically appropriate history and/or examination

• The required level of MDM, such as moderate

• The total time requirement, such as a minimum of 70 minutes on the date of the encounter

When you bring that all together, it looks like this example code with the official descriptor shown in italics: 99235 Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded.

As noted above, CPT^® revised office and other outpatient E/M codes 99202-99215 in 2021. The codes received another update in 2024 to adjust the phrasing of the time requirements from a range of total time to a minimum time that must be met or exceeded, like the other updated E/M codes. The exception is 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, which does not have a time requirement.

Commonly Used E/M Terms

Below are definitions to help you understand E/M terminology.

A qualified healthcare professional is “an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service,” according to CPT^® guidelines. E/M code descriptors and rules often refer to “physicians and other qualified health care professionals.” Examples include advanced practice nurses (APNs) and physician assistants (PAs). Clinical staff members do not fall in this category.

A clinical staff member is “a person who works under the supervision of a physician or other qualified health care professional, and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specific professional service but does not individually report that professional service,” CPT^® guidelines state.

A professional service is a face-to-face service by a physician or other qualified healthcare professional who can report E/M codes. This definition of a professional service is specific to E/M coding for distinguishing between new and established patients.

A new patient is a patient who has not received any professional services (remember, that means face-to-face services) within the past three years from the physician or qualified healthcare professional providing the current E/M service, or from another physician or qualified healthcare professional of the same specialty and subspecialty who is part of the same group practice. That’s the definition of new patient according to AMA CPT^® E/M guidelines. Medicare refers only to the same physician specialty (not subspecialty) in its definition of new patient for E/M coding, available in Medicare Claims Processing Manual, Chapter 12, Section 30.6.7.A. Physicians self-designate their Medicare specialty when they enroll, choosing from the list of specialty codes in Medicare Claims Processing Manual, Chapter 26, Section 10.8.2.

• The following is an example of a new patient E/M visit demonstrating the professional services rule: A 65-year-old male sees a cardiologist for an E/M service. Another cardiologist in the practice provided an interpretation of an EKG for the same patient the previous year when he was in the emergency department, but there was no face-to-face service. In this case, the cardiologist providing the E/M can still consider the patient to be new for E/M coding purposes because no cardiologist in the practice provided the patient with a face-to-face service within the past three years.

• The following is an example of a new patient E/M visit demonstrating the same-specialty rule: A patient has been seeing an internist in a multispecialty group for the past three years for primary care, particularly hypertension. The internist identified some suspicious lesions and sent the patient to a general surgeon in the same practice to evaluate lesion removal. The patient is a new patient to the general surgeon because the surgeon has a different specialty than the internist.

An established patient is a patient who has received professional (face-to-face) services within the past three years from the physician or qualified healthcare professional providing the E/M, or from another physician or qualified healthcare professional of the same specialty (and subspecialty, says AMA) who is part of the same group practice.

• The following is an example of an established patient E/M visit demonstrating the same-subspecialty rule: A pediatric patient comes to an office complaining of stomach pains. Although this is the pediatric gastroenterologist’s first time meeting the patient, another doctor of the same subspecialty in the same group practice saw the patient two years ago for a similar complaint. In this case, you should consider the patient to be established.

Scenarios for determining whether a patient is new or established can get complicated. The CPT^® guidelines provide this additional guidance:

• When a physician or qualified healthcare professional is on-call or covering for another provider, CPT^® guidelines instruct you to classify the patient encounter as new or established based on the patient’s relationship to the unavailable provider.

• When an APN or PA works with a physician, the CPT^® E/M guidelines state you should consider the APN or PA to be the same specialty and subspecialty as the physician.

The definitions of new patient and established patient for E/M coding are dense because there are so many elements involved. The decision tree below will help you determine whether a patient is new or established for an E/M encounter. The term QHP used in the graphic stands for qualified healthcare professional.

E/M Decision Tree: New vs. Established Patient

Levels of E/M Services

There are often three to five E/M service levels within each E/M code category or subcategory. Each level has its own E/M code. The intent behind the different levels of E/M services is to represent the variations in skills, knowledge, work, and time required for different encounters.

As noted above, for many E/M services, the MDM level or total time determines the E/M code level.

The time component does not apply to all E/M codes. For instance, you should not consider time to be a component for emergency department (ED) E/M services. Most ED services are provided in a setting where multiple patients are seen during the same time period, and it would be difficult to calculate time for any one patient. You can read more about the time component of E/M later in this article.

The component requirements for two E/M codes that are the same level may not be the same, so review each descriptor carefully before you make your final code choice.

Table 1 provides an example of how the E/M component requirements may vary between two codes even when those codes are both level-1 codes.

Table 1: Comparison of E/M Component Requirements for 99221 and 99231

MDM for E/M Coding

There are four types of MDM for E/M coding: straightforward, low, moderate, and high. The MDM concept does not apply to office or other outpatient visit code 99211 and emergency department code 99281, both of which “may not require the presence of a physician or other qualified health care professional,” per their descriptors.

The three elements of MDM are the number and complexity of problems addressed during the encounter, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management.

Those involved in coding should carefully read the E/M guidelines to understand each of these elements and how they relate to determining the MDM level.

Definition of Total Time for E/M

For many E/M codes, you may use the total time spent on the date of the encounter to determine which code applies.

Total time combines the face-to-face and non-face-to-face time the provider spends on the encounter on the encounter date. As a result, the total time may include tasks like reviewing tests before the patient is present or coordinating care after the patient leaves, as well as the time required for the visit. Clinical staff time is not counted in total time.

Just as with MDM, there are many additional rules and definitions that apply to total time, so reviewing and applying the E/M guidelines is essential to accurate coding.

What Is Not Included in E/M Codes

Along with knowing the factors that affect E/M code selection, you need to know what not to include in an E/M code:

• You may separately report performance and interpretation of diagnostic tests and studies ordered during the E/M service, assuming documentation meets those codes’ requirements for separate reporting.

• In some cases, reporting a procedure or service code on the same day as the code for a significant, separately identifiable E/M service may be appropriate.

  • The separate E/M can be prompted by the same symptoms or condition (diagnosis) the provider performed the other procedure or service for, but documentation must show that the E/M meets the requirements of the appropriate E/M code’s definition. In other words, you should not count work performed for the other procedure or service when you are determining the E/M code level.

  • You should append the appropriate modifier to the E/M code to show it meets requirements for separate reporting, 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.

Unlisted E/M Services and Special Reports

Two final basic E/M concepts you should know are unlisted services and special reports.

An unlisted E/M service is an E/M service that the CPT^® code set does not identify with a specific code. You should report these services using 99429 Unlisted preventive medicine service and 99499 Unlisted evaluation and management service. When you report these codes, the AMA’s CPT^® guidelines for E/M state you should use a “special report” to describe the service.

A special report is documentation that demonstrates the medical appropriateness of an unlisted service or a service that is new, is not usual, or may vary. In other words, the special report shows why a patient needed a particular service that doesn’t have a unique code, which may help support payment for the claim.

The report should include a clear description of the “nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service,” the CPT^® E/M guidelines state. Noting if the symptoms were particularly complex, what the final diagnosis was, relevant physical findings, procedures performed to diagnose or treat the patient, concurrent problems, and follow-up care also may help show medical necessity for the service.

For special reports that you are sending to payers, experts advise using plain language so that reviewers can understand what happened and why, even if they aren’t experts in the type of case involved.

Note: E/M coding has seen a lot of changes since 2021. For more information regarding updates, please see 99202-99215: Office/Outpatient E/M Coding in 2021 and 2023 E/M Coding Changes.

Last reviewed on June 6, 2024, by the AAPC Thought Leadership Team

E/M Code Categories