ModifiedFlorida BluePolicy N/A

Evaluation and Management for Office or Other Outpatient Services

Defines coding, time and medical decision-making (MDM) criteria, and billing rules for office or other outpatient E/M services (CPT 99202-99215) for Florida Blue lines of business and providers.

Policy Summary

PayerFlorida Blue

PolicyEvaluation and Management for Office or Other Outpatient Services

Policy CodePolicy N/A

Change TypeMaterial revision — requires G2212 for prolonged servicesclarifications to 99459

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionUse HCPCS G2212 for prolonged office/outpatient E/M services (each additional 15 minutes) and do not report G2212 with 99415/99416.

SourceLink

POLICY UPDATE CHANGES

Prolonged service reporting requirement updated to require HCPCS code G2212 instead of CPT code 99417.

Clarifying language for Pelvic Examination (CPT 99459) was added.

The Prolonged service (HCPCS code G2212) section has been revised; references reviewed and updated.

Policy revised to align with new reporting guidelines for E/M services (effective 01/01/2023 and 01/01/2024).

99202-99215Primary E/M codes covered

G2212Required prolonged code

99459Pelvic exam add-on

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Coverage criteria for office/outpatient E/M services

E/M coding and reimbursement criteria

Covered when ALL of the following selection and billing rules are met:

Select the appropriate office/outpatient E/M code (CPT 99202-99215) based on a medically appropriate history and/or physical examination and either the level of Medical Decision Making (MDM) OR the total time spent on the date of the encounter; for MDM, two of the three MDM elements must be met or exceeded.

ALL of the following

MDM comprises three elements: (1) number and complexity of problems addressed; (2) amount and/or complexity of data reviewed and analyzed; and (3) risk of complications and/or morbidity or mortality of patient management.
To qualify for a given MDM level, two of the three elements for that level must be met or exceeded; AMA CPT guidance and the CPT MDM table may be used to determine the appropriate level.

ALL of the following

Total time on the date of the encounter includes both face-to-face and non–face-to-face time by the reporting practitioner and must be documented in the medical record; time does not include services typically performed by clinical staff or services reported separately.
Shared/split visits based on time: sum the time of the physician and other qualified health care professionals for the visit; time spent together is counted once.
Examples of activities included when using time to select an E/M code: preparing to see the patient, performing the exam/evaluation, obtaining/reviewing history, counseling/education, ordering and reviewing tests, documenting, care coordination (when not separately reported), and independent test interpretation (when not separately reported).

ALL of the following

New patient: 99202 = 15 minutes; 99203 = 30 minutes; 99204 = 45 minutes; 99205 = 60 minutes.
Established patient: 99212 = 10 minutes; 99213 = 20 minutes; 99214 = 30 minutes; 99215 = 40 minutes.

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ALL of the following

99205 total time range = 60–74 minutes; 99205 + G2212 x1 = 89–103 minutes; additional G2212 units add 15-minute increments as specified in policy tables.
99215 total time range = 40–54 minutes; 99215 + G2212 x1 = 69–83 minutes; additional G2212 units add 15-minute increments as specified in policy tables.

ALL of the following

G2211 describes visit complexity inherent to certain office/outpatient E/M visits. For Commercial lines of business, G2211 is not separately reimbursed; for Medicare Advantage, appropriately reported G2211 may be allowed in alignment with CMS, but it will be denied if reported with the same visit as an E/M service with Modifier 25 by the same provider or if not appropriately reported.

ALL of the following

CPT 99459 is an add-on code for a pelvic examination that represents practice expense only; it is to be used with specified E/M or preventive codes and is not reportable when the pelvic exam is part of a gynecologic procedure.

ALL of the following

Services covered under this policy apply to claims reported on the CMS-1500 form or electronic equivalent; documentation must support selected code based on MDM or total time and include time documentation when time is used for code selection.
This payment policy is not an authorization or guarantee of payment; benefits are determined by the member's contract and medical necessity review where applicable.

ALL of the following

When selecting codes by MDM, follow the AMA CPT MDM table guidance; when selecting by time, include only time attributable to the reporting practitioner and exclude separately reported services or clinical staff time.

Document history and supporting references

Revision log entries and supporting references relevant to E/M and prolonged service reporting:

ALL of the following

Policy established 01/01/2021; annual reviews and subsequent revisions occurred on 01/13/2022, 01/01/2023, 01/01/2024, with additional revisions noted on 10/17/2024 and 01/09/2025.
Revisions aligned the policy with updated AMA/CMS E/M reporting guidelines and specifically revised prolonged service reporting to require HCPCS code G2212 (replacing CPT 99417) and added clarifying language for pelvic examination CPT 99459.

ALL of the following

10/17/2024: Clarifying language added for Pelvic Examination (CPT 99459).
01/09/2025: Annual review noted revision to the Prolonged service section requiring G2212; references were reviewed and updated.

Codes, time thresholds, and reporting rules

E/M and related add-on/prolonged codesCPT | HCPCS | mixedCovered

99202-99215	Office or other outpatient E/M services for new and established patients with selection by MDM or total time.
G2211	Visit complexity inherent to certain office E/M (add-on).
G2212	Prolonged office or other outpatient E/M service beyond maximum time of primary service (each additional 15 minutes).
99459	Pelvic examination add-on (practice expense only).

E/M and Prolonged Service Codes MentionedCPT

G2212	Prolonged service HCPCS code referenced as revised in 2025 review
99459	Pelvic Examination — clarifying language added

Time thresholds for code selection (total time on date)

New patient thresholds (minutes)99202 = 15; 99203 = 30; 99204 = 45; 99205 = 60

Established patient thresholds (minutes)99212 = 10; 99213 = 20; 99214 = 30; 99215 = 40

Prolonged service incrementG2212 = each additional 15 minutes beyond the primary E/M service

Guideline alignment dates

Policy establishedEffective date: 2021-01-01

Major CMS/AMA alignmentGuideline alignment effective dates: 2023-01-01 and 2024-01-01

Provider responsibilities and operational guidance

Documentation Required

Authorization and applicability

THIS PAYMENT POLICY IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS PAYMENT POLICY APPLIES TO ALL LINES OF BUSINESS AND PROVIDERS OF SERVICE. IT DOES NOT ADDRESS ALL POTENTIAL ISSUES RELATED TO PAYMENT FOR SERVICES PROVIDED TO FLORIDA BLUE MEMBERS; LEGISLATIVE MANDATES, PROVIDER CONTRACT DOCUMENTS, OR THE MEMBER'S BENEFIT COVERAGE MAY SUPERSEDE THIS POLICY.

Note

References and Guideline Updates

References and guideline updates relevant to reporting, billing, and coding for office/outpatient Evaluation and Management (E/M) services and prolonged services. Providers should follow current CMS and AMA guidance when selecting and reporting E/M codes and prolonged services, and monitor the listed references for updates that may affect billing and reimbursement.

Follow CMS and AMA E/M documentation and coding guidance for services on or after 01/01/2021.
Be aware of CMS guidance affecting payment policy under the Physician Fee Schedule (CY 2021 and later).

Key definitions used in this policy

Medical Decision Making (MDM)

MDM elementsNumber/complexity of problems; amount/complexity of data reviewed and analyzed; risk of complications/morbidity or mortality

MDM rule for level selectionTo qualify for an MDM level, two of the three elements for that level must be met or exceeded

Data categoriesData includes tests/documents/orders/independent historians; discussions with external providers; independent test interpretation

Total time

Definition of Total timeSum of face-to-face and non-face-to-face time spent by the reporting practitioner on the date of the encounter; must be documented in the medical record

ExclusionsDoes not include time for services typically performed by clinical staff or services reported separately (e.g., separately coded care coordination)