Evaluation and Management Coding Flashcards

According to 2024 CPT guidelines for Evaluation and Management (E/M) services, how is the level of service for an office or other outpatient visit selected when based on time?

Answer: The provider must meet or exceed a single minimum time threshold for the code.

For 2024, the AMA revised the time-based coding guidelines for office and other outpatient E/M services (99202-99205, 99212-99215). The previous time ranges were removed from the code descriptors and replaced with a single minimum total time that must be met or exceeded on the date of the encounter.

A physician performs an extensive history and examination and spends a total of 85 minutes on the date of the encounter for a new patient office visit. The medical decision making (MDM) is of high complexity. The time for CPT code 99205 is 60 minutes. Which of the following is the correct way to report the prolonged service?

Answer: Report 99205 and add-on code 99417 for the additional time beyond the minimum time for 99205.

CPT add-on code +99417 is used to report prolonged office or other outpatient E/M services. It is used when the total time on the date of the encounter exceeds the minimum time for the highest-level service (99205 or 99215) by at least 15 minutes. In this case, 85 minutes exceeds the 60-minute threshold for 99205 by 25 minutes, justifying the use of 99417.

When determining the level of Medical Decision Making (MDM) for an E/M service, which of the following is NOT one of the three main elements considered?

Answer: The severity of the patient's chief complaint.

The three elements of Medical Decision Making (MDM) are: 1) Number and Complexity of Problems Addressed, 2) Amount and/or Complexity of Data to be Reviewed and Analyzed, and 3) Risk of Complications and/or Morbidity or Mortality of Patient Management. The patient's chief complaint is the reason for the visit but is not one of the three formal elements for leveling MDM.

An established patient is seen in the office for two separate, unrelated problems on the same day by the same physician. The first visit in the morning addresses a minor, self-limited issue. The second visit in the afternoon is for an acute, uncomplicated illness. How should these services be coded?

Answer: Report a single E/M code that combines the complexity and/or time of both encounters.

For E/M services, when multiple visits occur on the same calendar date in the same setting by the same provider, a single E/M service is reported. If coding based on MDM, the coder should use the aggregated MDM for the entire day. If coding based on time, the total time for the day should be summed.

A physician and a non-physician practitioner (NPP) in the same group practice both have face-to-face encounters with a patient on the same day for a shared/split E/M visit. If coding is based on time, who reports the service?

Answer: The professional who spent the majority of the total time for the service.

For split/shared E/M services, when the code selection is based on total time, the service is reported by the professional (physician or NPP) who spent more than half of the total face-to-face or non-face-to-face time performing the service.

A patient is admitted to the hospital for observation and discharged on the same calendar date. The total time of the stay is 10 hours. Which set of CPT codes should be used to report these services?

Answer: An admission and discharge on the same day code (99234-99236).

CPT codes 99234-99236 are specifically designated for reporting hospital inpatient or observation care services, for admission and discharge on the same date of service. A key requirement for using these codes is that the patient's stay must be for more than 8 hours.