Evaluation and Management (E/M) Flashcards

According to 2023 CPT guidelines for Evaluation and Management (E/M) services, how is the level of service selected for most categories like office visits, hospital care, and consultations?

Answer: Based solely on the level of medical decision making (MDM) or the total time spent on the date of the encounter.

As of 2023, the guidelines for selecting an E/M service level for most categories were revised to be based on either the level of Medical Decision Making (MDM) or the total time spent by the provider on the date of the encounter. The previous requirement to meet or exceed specific levels of history and physical exam was eliminated for code selection.

An established patient is seen for a follow-up visit for two stable chronic illnesses and one new, uncomplicated problem. The physician performs a medically appropriate history and exam. The medical decision making involves a limited amount of data to be reviewed and a low risk of morbidity from patient management. How many of the three MDM elements must be met or exceeded to qualify for a particular level of MDM?

Answer: Two of the three elements must be met or exceeded.

To qualify for a given level of Medical Decision Making (MDM), CPT guidelines require that two of the three elements of MDM (Number and Complexity of Problems Addressed, Amount and/or Complexity of Data to be Reviewed and Analyzed, and Risk of Complications and/or Morbidity or Mortality of Patient Management) must be met or exceeded.

A physician spends a total of 65 minutes with an established patient for an office visit, which includes reviewing records, the face-to-face exam, and documenting in the EHR after the patient leaves. The time is properly documented. The highest level office visit code for an established patient, 99215, has a time threshold of 40 minutes. Which of the following is the correct way to report the prolonged service time?

Answer: Report CPT code 99215 and add-on code 99417.

For prolonged office or other outpatient E/M services, when time is used for code selection and the time of the highest-level code (e.g., 99215) is exceeded by at least 15 minutes, add-on code +99417 is used to report each additional 15-minute increment. CPT codes 99354-99357 were deleted for this purpose.

Which of the following activities performed by a physician on the date of an E/M encounter can be included when calculating total time for time-based coding?

Answer: Counseling and educating the patient and/or family.

Total time for E/M coding includes the time the physician or other qualified health care professional personally spends on the date of the encounter. This includes activities like preparing to see the patient, performing the exam, counseling the patient/family, ordering tests, and documenting in the health record. Time spent by ancillary staff or time spent on other dates is not included.

A patient is admitted to hospital inpatient care and discharged on the same date of service. Which CPT code range should be used to report these services?

Answer: 99234-99236 for hospital inpatient or observation care, including admission and discharge services on the same date.

CPT codes 99234-99236 are specifically designated for reporting hospital inpatient or observation care services when the patient is admitted and discharged on the same date of service. These codes bundle the admission and discharge work into a single service.

Which E/M category is unique in that the level of service is NOT selected based on either Medical Decision Making (MDM) or total time?

Answer: Emergency Department Services

Emergency Department (ED) E/M services (99281-99285) are an exception to the general rule. The level of service for ED visits is selected based solely on the level of Medical Decision Making (MDM). Total time is not used to select a code level in the emergency department setting.