CurrentHighmark DelawarePolicy N/A

Documentation Requirements for Evaluation and Management (E/M) Services

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.

Policy Summary

PayerHighmark Delaware

PolicyDocumentation Requirements for Evaluation and Management (E/M) Services

Policy CodePolicy N/A

Change TypeCoding and documentation updates (2024 time thresholds)prior alignment with AMA CPT (2023)consultation code removal (2021)

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionWhen reporting outpatient E/M by time, document start/stop times and total time.

SourceLink

POLICY UPDATE CHANGES

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.

99202-99205, 99212-99215Office/outpatient E/M codes affected

99306, 99308Skilled nursing codes affected

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

E/M Selection and Documentation Criteria

E/M selection and documentation criteria

Criteria for selecting E/M level and required documentation:

Medical record must clearly document observations, findings, diagnostic tests and procedures, diagnoses, treatments, follow-up care, and outcomes for each encounter; all services performed and related diagnoses must be documented.

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.

MDM is defined by three components: (1) number and complexity of problems addressed; (2) amount and/or complexity of data to be reviewed and analyzed; and (3) risk of complications and/or morbidity or mortality of patient management. To choose an E/M level by MDM, meet or exceed at least two of the three components (the MDM concept does not apply to CPT codes 99211 and 99281).

Amount/complexity of data: include medical records, tests, other information obtained/ordered/reviewed/analyzed, information from multiple sources or interprofessional communications, and interpretations not reported separately; ordering a test and reviewing its result are part of the encounter.

Data elements counted include unique tests, independent interpretations, and interprofessional communications; document ordering, review, and findings; external sources are counted per policy definitions.

Risk considerations: document comorbidities, planned or performed invasive procedures, referrals, and shared decision making; determine risk level based on management decisions and potential consequences.

If selecting level by time for outpatient E/M, document both start and stop times and the total time treating the patient; use the time defined in the service descriptors to select the appropriate level. Count only activities listed in policy (e.g., review of tests, ordering, obtaining/reviewing separately obtained history, exam/evaluation, referrals/communications, counseling/education, documentation, independent interpretation and communication of results, care coordination) and do not count time for services reported separately, travel, or general teaching not specific to patient management.

Effective January 1, 2024, time ranges were removed from new and established office/outpatient E/M codes; the time threshold to meet is now the lowest number of minutes in the prior code range. Minimum time values for specified skilled nursing facility codes were increased by 5 minutes. (Affected codes: 99202-99205, 99212-99215, 99306, 99308.)

Do not report outpatient or inpatient consultation codes (e.g., 99241-99245 or 99251-99255); report services using the appropriate E/M codes instead.

Codes and Time Rules

E/M codes with updated time rulesCPT

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

Time documentation requirement

Required time documentationRecord start and stop times and the total time when using time to select outpatient E/M codes; the Plan requires both start/stop times and total time be documented.

Applicable codesOffice/outpatient visits 99202-99205 and 99212-99215; skilled nursing 99306 and 99308 (minimum times increased by 5 minutes).

Time threshold ruleTime threshold is the lowest number of minutes in the prior code range (effective Jan 1, 2024).

Counting activitiesCount patient-specific activities such as test review, ordering tests/meds, history review, exam, referrals/communications, counseling/education, documentation, independent interpretation, and care coordination (if not reported separately).

Excluded timeDo not count time for services reported separately, travel, or general teaching not specific to patient management.

Required Documentation and Billing Actions

Billing Rule

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

Documentation Required

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.

Key Definitions (MDM and Related Terms)

MDM

DefinitionMedical Decision Making (MDM) is the process of establishing diagnoses, assessing condition status, and/or selecting management options; four recognized levels: straightforward, low, moderate, high.

Three MDM componentsNumber/complexity of problems; amount/complexity of data to be reviewed and analyzed; risk of complications or morbidity/mortality of patient management.

Level determinationTo select an E/M level by MDM, two of the three components must be met or exceeded (does not apply to codes 99211 or 99281).

MDM scope noteMDM elements inform diagnosis, condition assessment, and management decisions used for selecting E/M level.

Data elements (for MDM)

Analyzed data (counting)Data counted when used in MDM includes tests ordered/reviewed/analyzed and independent interpretations; tests ordered during an encounter are presumed analyzed and count in that encounter.