The process by which office and other outpatient evaluation and management (E&M) levels (CPT® 99202 – 99215) are selected was changed by the AMA CPT® Editorial Panel effective January 1, 20211 . This was a welcome change as it resulted in the removal of barriers that made it difficult for some specialists to reach higher level office and other outpatient E&M levels. Effective January 1, 20232, under the guidance of the AMA CPT Editorial Panel, these same changes will also be applied to the method used to select the level of these E&M services:

  • Hospital Inpatient and Observation Care
  • Consultation
  • Emergency Department
  • Nursing Facility
  • Home or Residence

With this change, the levels of office or other outpatient, hospital inpatient and observation care, consultation, emergency department, nursing facility, and home or residence E&M services will be selected based on medical decision making only or total time only.

Medical Decision Making

Effective January 1, 20232, when using medical decision making to determine the E&M level for any of these E&M types, the four medical decision making levels are:

  • Straightforward Medical Decision Making
  • Low Medical Decision Making
  • Moderate Medical Decision Making
  • High Medical Decision Making

When choosing the E&M level based on medical decision making, three elements of medical decision making are considered:

  • Number and Complexity of Problems Addressed
  • Amount and/or Complexity of Data to be Reviewed and Analyzed
  • Risk of Complications and/or Morbidity or Mortality of Patient Management

Effective January 1, 20232, each of these E&M types will have its own thresholds of those three elements. When reviewing an encounter, if what was medically necessary, performed, and documented meets the thresholds of two of a level’s three elements, that E&M level may be selected. AMA CPT shares the details of each of those thresholds here https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf.

Total Time

Effective January 1, 20232, when using time to determine the office or other outpatient, hospital inpatient and observation care, consultation, emergency department, nursing facility, and home or residence E&M level the total time spent by the provider performing the evaluation and management on the calendar date of the encounter is considered. Each of the CPT code descriptors for the E&M types listed in this article includes a time value in minutes.


Reference

1 American Medical Association CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes.  https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

2 https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

  • Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2021 by the American Medical Association. All rights reserved.CPT is a registered trademark of the American Medical Association (AMA).
Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC
Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Dr. Lehrman is in private practice in Fort Collins, CO and operates Lehrman Consulting, LLC. He is a Diplomate of the American Board of Foot and Ankle Surgery, Fellow of the American Society of Podiatric Surgeons, and is recognized as a “Master” by the American Professional Wound Care Association. He is a Fellow of the American Academy of Podiatric Practice Management and an Expert Panelist on Codingline. In his role as a Consultant to the APMA Health Policy and Practice Department, Dr. Lehrman serves as an advisor to the APMA Coding Committee and the APMA MACRA Task Force. Dr. Lehrman sits on the board of directors of both the American Professional Wound Care Association and the American Society of Podiatric Surgeons. He is also on the editorial advisory board of the journal WOUNDS.