Coverage and payment are contingent on correct coding, adequate documentation, and meeting E/M selection rules based on medical decision making (MDM) or total time.
Claims must be coded with the correct combination of procedure codes; professional claims should include all appropriate codes related to services rendered.
Refer to current AMA CPT guidance for code descriptions and time parameters.
Medical record documentation must indicate presenting symptoms, diagnoses, treatment plan, and written orders when applicable; documentation should support the extent of history/exam, MDM, and total time when time is used.
Medical records and itemized bills may be requested for claim review.
Providers must select the appropriate E/M level based on either the level of Medical Decision Making (MDM) or the total time spent by the physician or QHP on the date of the encounter.
When time is used, include face-to-face and non–face-to-face time personally spent by the reporting clinician; documentation should support the time for each code billed.
To qualify for an MDM level, two of the three MDM elements (number/complexity of problems, amount/complexity of data reviewed, and risk of complications/morbidity/mortality) must be met or exceeded.
See MDM descriptions and examples for Straightforward, Low, Moderate, and High complexity levels.
Office/outpatient E/M codes (CPT 99202-99205 for new patients; 99212-99215 for established patients) do not require documentation of the extent of history or exam for reimbursement when selected by MDM or time.
Time thresholds (examples) include: 99202 = 15–29 min (new)/99212 = 10–19 min (established); 99205 = 60–74 min (new)/99215 = 40–54 min (established).
Split/shared visits: when time is the basis for code selection, combine distinct provider times and report using modifier -FS with documentation identifying both providers and the substantive provider signature.
Follow split/shared documentation rules to support time-based coding.
Consultation CPT codes (99242-99245 and 99252-99255) will no longer be reimbursed effective 11/18/2024; report an appropriate E/M code for the location and complexity instead.
This is an effective policy change as of 11/18/2024.
Prolonged service codes have specific usage rules and documentation/time support requirements; they cannot be billed concurrently with certain other E/M or prolonged codes as specified.
See prolonged service guidance for allowable pairings and mutually exclusive reporting constraints.
Claims are subject to plan documents, provider contracts, medical policies, clinical payment and coding policies, and coding edits; plan documents and provider contracts govern when conflicts occur.
Claims may be reviewed and edited prior to payment.