Documentation Requirements for Evaluation and Management (E/M) Services
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Defines required medical record documentation and rules for selecting E/M levels (history, exam, medical decision making, and time) for providers submitting claims to Highmark Delaware; affects clinicians billing office/outpatient, nursing facility, and other E/M services to the Plan.
Effective January 1, 2024, office and outpatient E/M coding removed time ranges from new and established outpatient codes and the time threshold is now the lowest number of minutes in the prior ranges; nursing facility care code minimum times increased by 5 minutes.
Effective January 1, 2023, the Plan aligned E/M coding with AMA CPT Panel changes allowing selection of E/M level by Medical Decision Making (MDM) or time (except ED services, which remain MDM only).
The Plan no longer recognizes outpatient and inpatient consultation codes; these should be reported with appropriate E/M codes.
E/M Selection and Documentation Criteria
E/M selection and documentation criteria
Criteria for selecting E/M level and required documentation:
Level selection method
- Clinician may select E/M level based on Medical Decision Making (MDM).
- Clinician may select E/M level based on time for office/outpatient and other E/M services except Emergency Department which remains MDM only.
Codes and Time Rules
| 99202-99205 | Office or outpatient visit (new); time thresholds changed to use the minimum minutes of prior ranges |
| 99212-99215 | Office or outpatient visit (established); time thresholds changed to use the minimum minutes of prior ranges |
| 99306 | Skilled nursing facility care code with increased minimum time value |
| 99308 | Skilled nursing facility care code with increased minimum time value |
Required Documentation and Billing Actions
Consultation code removal
The Plan no longer recognizes consultation codes. Report outpatient and inpatient consultation services using the appropriate Evaluation and Management (E/M) code rather than CPT consultation codes.
- Affected codes: 99241-99245, 99251-99255
- Reference: See Reimbursement Policy RP-063 in the Provider Resource Center
Provider action: Consultation code removal
When selecting an E/M code in place of a consultation code, ensure the encounter documentation supports the E/M level chosen (MDM or time where applicable). Retain all typical E/M documentation elements (history, exam, medical decision making) and, if choosing time, document start/stop times and total time per the E/M definitions.
- Do not bill consultation codes 99241-99245 or 99251-99255 — use the appropriate E/M code
- If reporting based on time, document start and stop times and total time, and list activities that count toward time
- Ensure documentation supports medical necessity and the selected E/M level
Key Definitions (MDM and Related Terms)
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