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Office and Other Outpatient E/M Services

Office and other outpatient evaluation and management (E/M) services describe encounters in which a physician or qualified health care professional (QHP) evaluates and manages a patient's health condition, symptoms, concerns, illnesses, injuries, diseases, or treatment needs in an office or outpatient setting.

Office and outpatient E/M services include:

  • 99202-99205 for new patients
  • 99211-99215 for established patients

A new patient is a patient who has not received professional services from the physician or QHP, or another physician or QHP of the same specialty and subspecialty within the same group practice, during the previous three years.

An established patient is a patient who has received professional services from the physician or QHP, or another physician or QHP of the same specialty and subspecialty within the same group practice, during the previous three years.

Office and outpatient E/M services are reported when the encounter includes the evaluation and management of one or more patient conditions, concerns, symptoms, findings, diagnoses, or treatment-related issues. Examples include:

  • Evaluation of new symptoms or conditions
  • Management of acute illnesses or injuries
  • Management of chronic conditions
  • Follow-up visits related to ongoing care
  • Medication management
  • Review and interpretation of diagnostic information
  • Care planning and coordination
  • Patient or caregiver counseling and education

The level of service is selected based on either:

  • Medical Decision Making (MDM), or
  • Total physician/QHP time on the date of the encounter

History and examination are performed as clinically relevant to the encounter; however, for office and outpatient E/M services, the extent of the history and examination does not determine the code level. Documentation of any history and examination performed remains part of the medical record and contributes to the evaluation and management of the patient.

Documentation of the Encounter

The medical record describes the reason for the encounter, the conditions or concerns evaluated, the provider's assessment, and the management decisions made during the visit. Documentation reflects the services furnished during the encounter and the clinical factors considered in patient care. 

For office and outpatient E/M services, history and examination are performed as medically appropriate, but the extent of the history and examination is not used to determine the code level. Documentation of any history and examination performed remains part of the medical record and support the care provided during the encounter. 

Selecting the Level of Service

Providers select the E/M level using either:

  • Medical Decision Making (MDM)
  • Total physician/QHP time on the date of the encounter

The level is selected using either MDM or total physician/QHP time consistent with the documentation for the encounter.

Using Time to Select the E/M Level

When selecting a code based on time, only physician or QHP time on the date of the encounter is counted. Time includes both face-to-face and qualifying non-face-to-face activities related to the patient. Time spent by clinical staff is not included. 

Activities included in total time:

  • Reviewing records, tests, and other information
  • Obtaining or reviewing history
  • Performing an examination
  • Counseling or educating the patient or caregiver
  • Ordering medications, tests, or procedures
  • Communicating with other health care professionals
  • Documenting in the medical record
  • Coordinating care

Only time spent on the encounter date is counted. Activities performed on a different date are not included in the total time calculation. 

Documentation Considerations for Time

When time is used to select the code level, documentation must reflect:

  • Total time spent
  • Significant activities performed during the encounter
  • Services or procedures excluded from the E/M time calculation

When a separately reportable procedure is performed on the same date, the time spent performing the procedure is not included in the E/M service time.

Using Medical Decision Making (MDM)

MDM is based on three elements:

  1. Number and complexity of problems addressed
  2. Amount and complexity of data reviewed and analyzed
  3. Risk of complications and/or morbidity or mortality of patient management

The MDM level is determined by meeting or exceeding the requirements of two of the three elements. MDM levels include straightforward, low, moderate, and high. 

Number and Complexity of Problems Addressed

A problem is considered addressed when it is evaluated or managed during the encounter. Problems addressed include symptoms, findings, complaints, conditions, illnesses, injuries, or diagnoses.

Documentation describes:

  • New concerns evaluated during the visit
  • Chronic conditions evaluated or managed
  • Changes in a patient's status
  • Responses to treatment
  • Goals discussed during the encounter

Conditions listed in the medical record but not evaluated or managed during the encounter are not counted toward this MDM element.

Amount and/or Complexity of Data Reviewed and Analyzed

This element reflects information reviewed, ordered, analyzed, interpreted, or discussed as part of patient management.

Examples include:

  • Review of external medical records
  • Review of diagnostic testing
  • Ordering diagnostic tests
  • Use of an independent historian when needed
  • Independent interpretation of a test when the interpretation is not separately reported
  • Discussion of patient management or test interpretation with an external physician, qualified health care professional, or other appropriate source

Documentation reflects the information reviewed, ordered, analyzed, interpreted, or discussed as part of the medical decision-making for the encounter.

Risk of Patient Management

Risk reflects management decisions made during the encounter and the potential consequences associated with those decisions. Risk is evaluated in the context of the patient's condition and treatment plan.

Examples within the risk element include:

  • Prescription drug management
  • Decisions regarding surgery
  • Decisions regarding hospitalization
  • Drug therapy requiring intensive monitoring for toxicity
  • Diagnosis or treatment significantly limited by social determinants of health

Documentation describes treatment options considered, discussions with the patient, medications managed, monitoring plans, referrals, or other management decisions made during the encounter.

Prescription Drug Management

Prescription drug management include activities such as:

  • Initiating a medication
  • Continuing a medication while evaluating treatment response
  • Adjusting dosage
  • Discontinuing therapy
  • Monitoring medication-related concerns
  • Evaluating prescription drug management options, including situations where a medication is not prescribed
  • Documenting a patient's decision to decline a recommended medication

The documentation reflects the condition evaluated or managed and the medication-related decision making performed during the encounter.

External Records, Tests, and Consultations

Review of records and test results frequently contributes to management decisions. Documentation identifies:

  • External notes reviewed
  • Tests ordered or reviewed
  • Independent historian involvement
  • Discussions with external practitioners
  • Independent interpretation of diagnostic studies when applicable

Documentation reflects the review, analysis, interpretation, or discussion performed during the encounter and its role in patient management.

Prolonged Services

HCPCS code G2212 may be reported with 99205 or 99215 when time is used to select the office or outpatient E/M service and the total time for the encounter meets the CMS prolonged service threshold. G2212 is not reported when MDM is used to select the office or outpatient E/M level.

Preventive and Problem-Oriented Services on the Same Date

When a preventive service and a problem-oriented E/M service are furnished on the same date, documentation identifies the preventive service and the work associated with the problem-oriented E/M service as distinct services when both are reported on the same date.

When time is used, the time associated with the preventive service is not included in the E/M time calculation. When MDM is used, the documentation must support the separately identifiable problem-oriented service.

Teaching Physician 

For teaching physician services, only the teaching physician's qualifying time is used when time determines the E/M level. With the primary care exception, MDM is used for visit level selection rather than time.

Incident To

For incident to services, Medicare incident-to requirements continue to apply. Clinical and ancillary staff services support code 99211 when the applicable requirements are met.

HCPCS Code G2211

CMS established HCPCS code G2211 to recognize visit resources associated with serving as the continuing focal point for a patient's health care needs or providing ongoing care related to a serious or complex condition. G2211 is reported with office and outpatient E/M services when CMS billing requirements are met.

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