CurrentBlue KCPolicy POL-PP-236

Evaluation and Management (E/M) Guidelines

This document governs Blue KC's guidance for selecting E/M service levels based on medical decision making (MDM) or time, applicable to clinicians reporting office, hospital, observation, emergency, facility, and critical care E/M codes.

Policy Summary

PayerBlue KC

PolicyEvaluation and Management (E/M) Guidelines

Policy CodePolicy POL-PP-236

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review DateJan 1, 2027

Key ActionWhen time is used for reporting E/M codes, use the total time on the date of the encounter (face-to-face and non-face-to-face time personally spent by the clinician) to determine level selection.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99202-99215Office/outpatient codes

99221-99223Initial hospital codes

Time or MDMPrimary selection methods

7-9Pages in extract

E/M Selection Criteria

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E/M level must be selected using medical decision making or total time when allowed by the service descriptor

When time is used for level selection, meet ALL of the following

Use the total time on the date of the encounter (includes both face-to-face and non-face-to-face time personally spent by the physician or other qualified health care professional)
Include time regardless of the clinician's location (on- or off-unit, in or out of office)
Exclude any time spent on separately reported services — providers must carve out time for billable services from E/M time
Count physician/qualified health care professional activities such as preparing to see the patient, review of tests, obtaining/reviewing history, exam/evaluation, counseling/education, ordering, referrals/communication (when not separately reported), documentation, independent interpretation (not separately reported), and care coordination
Do not count time spent on travel or general teaching not limited to management of the specific patient

For office/outpatient encounters, if the clinician's time on the date of the encounter is spent supervising clinical staff who perform the face‑to‑face services, report 99211

Monitoring may affect the level of MDM only when it is considered in management decisions and meets appropriate frequency/intensity thresholds (e.g., not infrequent routine monitoring); long‑term intensive monitoring that influences MDM should occur at least quarterly

Risk level for MDM is based on the consequences of the problems addressed and includes the need to initiate or forego tests, treatments, or hospitalization

Independent interpretation of tests (where a CPT code exists) should be documented and may be included in E/M time when not separately reported; a full separate report is not required unless already reported by another clinician

Codes and Coding Guidance

Office/Other Outpatient E/M CodesCPT

99202-99215

Office or other outpatient E/M services; level selection by MDM or total time

Initial Hospital Inpatient/Observation E/M CodesCPT

99221-99223

Initial hospital inpatient or observation care; level selection by MDM or total time

Subsequent Hospital Inpatient/Observation E/M CodesCPT

99231-99233

Subsequent hospital inpatient or observation care; MDM or total time

Hospital Inpatient/Observation Same-day Admit and Discharge E/M CodesCPT

99234-99236

Hospital inpatient/observation same-day admit/discharge; MDM or total time

Consultation - Office E/M CodesCPT

99242-99245

Consultation - office; MDM or total time

Consultation - Inpatient/Observation E/M CodesCPT

99252-99255

Consultation - inpatient/observation; MDM or total time

Emergency Department E/M CodesCPT

99281-99285

Emergency Department Services; MDM

Nursing Facility E/M CodesCPT

99304-99310

Nursing facility care; MDM or total time

Home or Residence E/M CodesCPT

99341-99350

Home or residence services; MDM or total time

Neonatal/Pediatric Critical/Intensive Care CodesCPT

99468-99476

Neonatal/pediatric critical/intensive care; total time

Critical Care CodesCPT

99291-99292

Critical care; total time

Monitoring frequency — impact on MDM

Monitoring threshold for MDMMonitoring contributes to Medical Decision Making only when it is part of patient management and meets frequency/intensity thresholds (not infrequent annual checks)

Examples that qualifyMonitoring that assesses/manage treatment toxicity (e.g., cytopenia monitoring between antineoplastic dose cycles)

Examples that do NOT qualifyRoutine glucose monitoring during insulin therapy or annual electrolytes/renal function for chronic diuretic use due to insufficient frequency or primary therapeutic purpose

Long‑term intensive monitoring frequencyLong-term intensive monitoring is not performed less than quarterly

Time-Based Reporting & Provider Instructions

Billing Rule

Use total date‑of‑encounter time to select E/M level; exclude separately reported services

When reporting E/M codes by time, use the total time spent on the date of the encounter (both face-to-face and non‑face‑to‑face time personally performed by the clinician) to select the level of service. Time must exclude any periods spent performing separately reportable services; for office/outpatient encounters when the clinician’s time is spent supervising clinical staff who perform the face‑to‑face services, report 99211.

Total time = face‑to‑face + non‑face‑to‑face time personally spent by the physician or qualified health care professional on the date of the encounter (includes preparation, review of tests, counseling, ordering, documentation, independent interpretation, care coordination).
Do not count time spent on separately reported billable services — providers must carve out that time from E/M time.
If clinician time is supervisory of staff providing the face‑to‑face service in office/outpatient settings, report CPT 99211.

Defined Terms

Independent interpretation

DefinitionInterpretation of a test for which there is a CPT code; a form of interpretation should be documented but need not be a complete separate report if the clinician reporting the E/M is not the same as the reporting clinician

When it does not applyDoes not apply when the clinician reporting the E/M service is reporting or has previously reported the test

Documentation expectationA form of interpretation should be documented even if it does not conform to the usual standards of a complete report

Risk (of complications, morbidity, or mortality)

DefinitionThe probability and/or consequences of an event as assessed by trained clinicians; assessment uses common terms such as high, medium, low, or minimal without requiring numeric quantification

Assessment basisBased on the nature of the event and usual physician reasoning; e.g., low probability of death may be high risk if consequences are severe

Use in MDMLevel of risk informs MDM based on consequences of problems addressed and need to initiate or forego tests, treatments, or hospitalization

Morbidity

DefinitionA state of illness or functional impairment expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment

Clinical implicationsMorbidity severity and duration factor into MDM and overall care planning

Relation to riskMorbidity contributes to assessment of risk for patient management decisions

Social determinants of health

DefinitionEconomic and social conditions that influence health of people and communities

ExamplesFood insecurity; housing insecurity

RelevanceConsideration of social determinants may inform care planning and MDM

Physician/qualified health care professional time — components

Included activitiesPreparing to see the patient (e.g., review of tests); obtaining/reviewing separately obtained history; performing exam/evaluation; counseling/education; ordering medications, tests, or procedures

Additional included activitiesReferring to and communicating with other health care professionals (when not separately reported); documenting clinical information in the health record

Other included activitiesIndependently interpreting results (not separately reported) and communicating results; care coordination (not separately reported)

Policy Dates & Revision History

2026-01-01Annual reviewLatest

Annual review: table added for code selection based on MDM and/or time, removed information for hospital facility observation, added Facility Observation Policy to related documents, and added link to AMA Medical Decision Making table.

2025-01-01Annual review

Annual review: removed detailed information on 2021 and 2023 E/M updates.

2024-01-01Annual review

Annual review: time range for new and established patient removed and added definition to substantive portion of shared visit in line with 2024 updates.

2023-03-08Update

Update: information on modifier FS (split/shared) added.

2023-01-30Update

Update: information on 48-hour Facility Observation added.

2023-01-01Initial version

Initial version: policy created and made effective (Original Creation Date/Version Effective Date 1/1/2023).