medical visit cpt code

Follow these four steps to code quickly and accurately, while reducing the need to count up data points.

KEITH W. MILLETTE, MD, FAAFP, RPh

Fam Pract Manag. 2021;28(4):21-26

Author disclosure: no relevant financial affiliations.

The new rules for coding evaluation and management (E/M) office visits are a big improvement but still a lot to digest. 1 , 2 To ease the transition, previous FPM articles have laid out the new American Medical Association/CPT medical decision making guide 3 and introduced doctor–friendly coding templates (see “ Countdown to the E/M Coding Changes ,” FPM , September/October 2020), explained how to quickly identify level 4 office visits (see “ Coding Level 4 Visits Using the New E/M Guidelines ,” FPM , January/February 2021), and applied the new guidelines to common visit types (see “ The 2021 Office Visit Coding Changes: Putting the Pieces Together ,” FPM , November/December 2020).

After several months of using the new coding rules, it has become clear that the most difficult chore of coding office visits now is assessing data to determine the level of medical decision making (MDM). Analyzing each note for data points can be time-consuming and sometimes confusing.

That being the case, it's important to understand when you can avoid using data for coding, and when you can't. I've developed a four-step process for this (see “ A step-by-step timesaver ”).

The goal of this article is to clarify the new coding rules and terminology and to explain this step-by-step approach to help clinicians code office visits more quickly, confidently, and correctly.

The new evaluation and management office visit coding rules have simplified many things but are still a lot to digest, especially when it comes to counting data.

There are different levels of data and different categories within each level, which can make using data to calculate the visit level time-consuming and confusing.

By calculating total time, and then moving on to assessing problems and prescription drug management, most visits can be optimally coded without dealing with data at all.

OFFICE VISIT CODING RULES AND TERMINOLOGY

To make full use of the step-by-step process, we have to first understand the new rules, as well as coding terminology. Here is a brief summary.

Medically appropriate . Physicians and other qualified health care professionals may now solely use either total time or MDM to determine the level of service of an office visit. That means the “history” and “physical exam” components are no longer needed for code selection, which simplifies things. But your patient note must still contain a “medically appropriate” history and physical. So continue to document what is needed for good medical care.

New patient . A new patient is a patient who has not been seen by you or one of your partners in the same medical specialty and the same group practice within the past three years.

Total time and prolonged services . Total time includes all the time you spend on a visit on the day of the encounter (before midnight). It includes your time before the visit reviewing the chart, your face-to-face time with the patient, and the time you spend after the visit finishing documentation, ordering or reviewing studies, refilling medications, making phone calls related to the visit, etc. It does not include your time spent performing separately billed services such as wellness visits or procedures. Total time visit level thresholds differ for new patients vs. established patients. (See the total times in “ The Rosetta Stone four-step template for coding office visits .”)

The prolonged services code comes into play when total time exceeds the limits set for level 5 visits by at least 15 minutes.

Medical decision making . MDM is made up of three components: problems, data, and risk. Each component has different levels, which correspond to levels of service (low/limited = level 3, moderate = level 4, and high/extensive = level 5). The highest level reached by at least two out of the three components determines the correct code for the level of service. MDM criteria is the same for new and established patients.

Problems addressed . This includes only the problems you address at that specific patient visit. It does not include all the patient's diagnoses and does not include problems that are exclusively managed by another clinician. Problems addressed are separated into low-complexity problems (level 3), moderate-complexity problems (level 4), and high-complexity problems (level 5). To code correctly, you need to know the coding value of the problems you address. It is helpful to think of problems in terms of levels of service (e.g., a sinus infection is usually a level 3 problem, and pneumonia or uncontrolled diabetes are usually level 4 problems).

The simplest way to summarize problems is this: Life-threatening problems are level 5; acute or chronic illnesses or injuries are level 3 or 4 depending on how many there are, how stable they are, and how complex they are; and if there's just one minor problem, it's level 2.

(For more specifics see “ What level of problem did I address? ”)

Risk . Risk is also separated into “low” (level 3), “moderate” (level 4), and “high” (level 5) categories.

Level 3 risk includes the use of over-the-counter (OTC) medications.

Level 4 risk includes the following:

Prescription drug management: starting, stopping, modifying, refilling, or deciding to continue a prescription medication (and documenting your thought process),

Social determinants of health that limit diagnosis or treatment (this is when patients' lack of finances, insurance, food, housing, etc., affects your ability to diagnose, manage, and care for them as you normally would).

Level 5 risk includes the following:

Decisions about hospitalization,

Decisions about emergency major surgery,

Drug therapy that requires intensive toxicity monitoring,

Decisions to not resuscitate or to de-escalate care because of poor prognosis.

Data analyzed . For purposes of MDM, data is characterized as “limited” (level 3 data), “moderate” (level 4 data), or “extensive” (level 5 data). But each level of data is further split into Categories 1, 2, and 3. This can make calculating data complicated, confusing, and time-consuming. Here are the data components and terms you need to know.

Category 1 data includes the following:

The ordering or reviewing of each unique test , i.e., a single lab test, panel, X-ray, electrocardiogram (ECG), or other study.

Ordering and reviewing the same lab test or study is worth one point, not two; a lab panel (e.g., complete blood count or comprehensive metabolic panel) is worth one point,

Reviewing a pertinent test or study done in the past at your own facility or another facility,

Reviewing prior external notes from each unique source, including records from a clinician in a different specialty or from a different group practice or facility as well as each separate health organization (e.g., reviewing three notes from the Mayo Clinic is worth one point, not three, but reviewing one note from Mayo and one from Johns Hopkins is worth a total of two points),

Using an independent historian, which means obtaining a history from someone other than the patient, such as a parent, spouse, or group home staff member. (This is included in Category 2 for level 3 data, but falls into Category 1 for level 4 and 5 data.)

Category 2 data includes the following:

Using an independent historian (for level 3 data only),

Independent interpretation of tests, which is your evaluation or reading of an X-ray, ECG, or other study (e.g., “I personally reviewed the X-ray and it shows …”) and can include your personal evaluation of a pertinent study done in the past at your or another facility. It does not include reviewing another clinician's written report only, and it does not include studies for which you are also billing separately for your reading.

Category 3 data includes the following:

Discussion of patient management or test interpretation with an external physician, other qualified health care professional, or appropriate source. An external physician or other qualified health care professional is someone who is not in your same group practice or specialty. Other appropriate sources could include, for example, consulting a patient's teacher about the patient's attention deficit hyperactivity disorder.

A STEP-BY-STEP TIMESAVER

The majority of office visits can be optimally coded by using time or by looking at what level of problems were addressed (see Steps 1 and 2 below) and whether a prescription medication was involved.

A level 3 problem can be coded as a level 3 visit if you address it with an OTC or prescription medication. A level 4 problem can be coded as a level 4 visit if you order prescription medication or perform any other type of prescription drug management (modifying, stopping, or deciding to continue a medication). Most level 2 and level 5 office visits are straightforward, and most level 5 visits will be coded by time. They will typically be visits in which you address multiple problems or complicated problems and the total time exceeds 40 minutes for established patients. This is much more common than seeing critically ill patients who may require admission, which is another level 5 scenario. The few remaining patient visits that have not already been coded require analyzing data (Steps 3 and 4). (See “ The Rosetta Stone four-step template for coding office visits .”)

Step 1: Total time . Think time first. If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if it does not, go to Step 2.

Step 2: “Problems plus.” Don't be afraid to move on from time-based coding if you believe you performed a higher level visit using MDM. Many visits can be coded with MDM just by answering these two questions: What was the highest-level problem you addressed during the office visit? And did you order, stop, modify, or decide to continue a prescription medication?

If you addressed a level 2 problem and your total time was less than 20 minutes (or less than 30 for a new patient), then code level 2.

If you addressed a level 3 problem, plus you recommended an OTC medication or performed prescription drug management, then code level 3.

If you addressed a level 4 problem, plus you performed prescription drug management, then code level 4.

Chronic disease management often qualifies as level 4 work. For documentation, think “P-S-R”: problem addressed, status of the problem (stable vs. unstable), and prescription drug management (Rx). This trio should make it clear to coders, insurance companies, and auditors that level 4 work was performed.

For instance, if a patient has controlled hypertension and diabetes and you document that you decided to continue the current doses of losartan and metformin, that's level 4 (two stable chronic illnesses plus prescription drug management). If you see a patient with even one unstable chronic illness and document prescription drug management to address it, that's also level 4.

For a level 5 problem, if you see a really sick patient and decide to admit or consider admission (and you document your thought process in your note), then code level 5.

By starting with total time and, if necessary, moving on to “problems plus,” you will probably be able to optimally code 90% of your office E/M visits. But on the rare occasions when you see a patient for level 4 or 5 problems for less than the required time and don't do any prescription drug management, you may have to proceed to Steps 3 and 4.

Step 3: Level 4 problem with simple data or social determinants of health concerns . Code level 4 if you saw a patient for a level 4 problem and did any of the following:

Personally interpret a study (e.g., X-ray),

Discuss management or a test with an external physician,

Modify your workup or treatment because of social determinants of health.

Step 4: Level 4 or 5 problem with complex data . If you saw a patient for a level 4 problem and still haven't been able to code the visit at this point, you have to tally Category 1 data points:

Review/order of each unique test equals one point each,

Review of external notes from each unique source equals one point each,

Use of an independent historian equals one point.

Once you reach three points, code it as level 4.

For a level 5 problem, if you see a really sick patient, order/interpret an X-ray or ECG, and review/order two lab tests, then code level 5.

Following these steps should allow you to quickly identify the optimal level to code most any E/M office visit (for pre-op visits, see “ Coding pre-ops template .”)

Here's a catchy rhyme to remember the basic outline of the steps:

To finish fast ,

code by time and problems first ,

and save data for last .

By mastering the new coding rules and terminology and applying this four-step approach, you can code office visits more quickly, accurately, and confidently — and then spend more time with your patients and less time at the computer.

CPT Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Code and Guideline Changes . American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

E/M Office Visit Compendium 2021. American Medical Association; 2020.

Table 2 – CPT E/M office revisions level of medical decision making. American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

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Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

All specific references to CPT codes and descriptions are © 2023 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Download the Office E/M Coding Changes Guide (PDF)

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Evaluation and management (E/M) services are an essential part of medical practices, especially in family medicine. These services are categorized using Current Procedural Terminology (CPT) codes for billing purposes. Properly documenting and coding for E/M services is crucial to maximize payment and minimize audit-related stress.

There are different levels of E/M codes, determined by the medical decision-making or time involved. It’s worth noting that the guidelines for E/M coding have undergone changes, including the elimination of history and physical exam elements, revisions to the MDM table, and an expanded definition of time for E/M services.

Key Takeaways:

• Understanding E/M codes and guidelines is crucial for accurate billing.
• There are different levels of E/M codes based on medical decision-making or time involved.
• Recent changes to E/M coding include the elimination of history and physical exam elements.
• The definition of time for E/M services has been expanded.
• Proper documentation and coding help maximize payment and reduce audit-related stress.

Overview of Office Visit CPT Code Changes

The CPT Editorial Panel made significant revisions to the documentation and coding guidelines for office visit E/M services in 2021, with further changes introduced in 2023. These updates aim to simplify documentation requirements, reduce administrative burden, and ensure accurate coding for evaluation and management services.

One of the key changes introduced is the addition of add-on code G2211. This code accounts for the resource costs associated with visit complexity inherent to primary care and other longitudinal care settings. The inclusion of this add-on code reflects a more comprehensive understanding of the unique challenges and workload associated with these types of visits.

Additionally, the revisions eliminate the requirement for history and physical exam elements to be considered in E/M code level selection. This change allows healthcare providers to focus more on medical decision-making (MDM) and limits the need for extensive documentation of these elements in the medical record.

The MDM table has also been revised to better reflect the cognitive work required for evaluation and management services. This ensures that the complexity of the MDM is accurately captured in the coding process and supports appropriate reimbursement for the level of care provided.

Furthermore, the definition of time for many E/M services has been expanded. The expanded definition of time includes both face-to-face and non-face-to-face components of care on the day of the encounter. This change recognizes the comprehensive nature of care provided and allows for a more accurate reflection of the time spent in the management of the patient.

Using Total Time for Office Visit CPT Code Selection

When it comes to selecting the appropriate office visit CPT code, total time can be a valuable factor to consider. Total time refers to the sum of all the physician’s or qualified health professional’s (QHP) time spent in caring for the patient, both face-to-face and non-face-to-face, on the day of the encounter. This expanded definition of time allows for a more comprehensive evaluation and management of the patient’s needs.

Total time can be utilized in selecting the level of service for various evaluation and management services, including office visits, inpatient and observation care, consultations, nursing facility services, home and residence services, and prolonged services. It provides a broader perspective on the physician’s involvement in the patient’s care, taking into account all aspects of their interaction.

However, it’s important to note that for emergency department visits, the level of service is still determined primarily by medical decision-making (MDM), rather than total time. This distinction recognizes the critical nature of emergency care and the need for prompt assessment and action.

Accurate documentation of the total time spent is key to ensuring proper code selection and appropriate reimbursement. The total time should be well-documented in the patient’s medical record, including both the face-to-face and non-face-to-face components of the encounter. This documentation serves as a crucial reference point for billing and auditing purposes.

To summarize, total time offers a comprehensive perspective on the physician’s engagement with the patient, encompassing both face-to-face and non-face-to-face interactions. It allows for a more accurate selection of office visit CPT codes and ensures the appropriate level of reimbursement for the provided services. Proper documentation of total time is essential to support the medical necessity of the encounter and maintain compliance with coding and billing guidelines.

Documentation Requirements for Total Time Calculation

When determining the total time for selecting office visit CPT codes, it is essential to adhere to specific documentation requirements. By accurately documenting the time spent on various activities during the encounter, healthcare providers can ensure proper code selection and optimize reimbursement.

To calculate the total time for office visit code selection, the following activities should be included:

• Reviewing external notes/tests
• Performing an examination
• Counseling and educating the patient
• Documenting in the medical record

These activities reflect the time personally spent by the physician or qualified health professional (QHP) on the date of the encounter. However, there are also activities that should be excluded when calculating total time:

• Time spent on activities typically performed by ancillary staff
• Time related to separately reportable activities

It is crucial to specifically document the total time spent on each activity during the date of the encounter, rather than providing generic time ranges. This detailed documentation ensures transparency and accuracy in code selection and reimbursement.

In addition to capturing face-to-face time, it is important to record non-face-to-face time as well. Non-face-to-face time includes tasks performed outside of direct interaction with the patient, such as reviewing test results or consulting with other healthcare professionals.

Example of Total Time Calculation:

Let’s consider an example where a family physician spends the following time on a patient encounter:

• 45 minutes performing an examination and counseling
• 15 minutes reviewing external notes/tests
• 10 minutes documenting in the medical record
• 5 minutes discussing with an ancillary staff

In this case, the total time would be calculated as follows:

By accurately documenting the specific total time spent on each activity and excluding ancillary staff time, healthcare providers can ensure proper code selection and reimbursement. This meticulous documentation of total time in the medical record provides a comprehensive overview of the services rendered and supports accurate billing.

Split or Shared Visit Documentation Guidelines

A split or shared visit occurs when a physician and other qualified health professional (QHP) provide care to a patient together during a single Evaluation and Management (E/M) service. In such cases, the time personally spent by the physician and QHP on the date of the encounter should be summed to define the total time.

However, only distinct time should be counted. This means that overlapping time during jointly meeting with or discussing the patient should not be double-counted. The distinct time should represent the unique contribution of each provider involved in the split or shared visit.

It is important to note that time spent on activities performed by ancillary staff should not be included in the total time calculations. The total time should only reflect the face-to-face time and distinct time spent by the physician and other QHP directly involved in providing the medically necessary services.

Documentation should support the medical necessity of both services reported in a split or shared visit scenario. This includes clearly documenting the need for both physicians or QHPs to be involved and the services each provider contributed to the patient’s care.

Applying Total Time to Specific E/M Services

Total time is a valuable tool for selecting the appropriate level of service for a variety of Evaluation and Management (E/M) services. This method can be applied to different specific E/M services, ensuring that the level of care is clinically appropriate and adequately reimbursed. By considering the total time spent during the encounter, healthcare providers can accurately assign the appropriate office visit CPT code.

The application of total time is not limited to office visit services. It can also be used for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services. This flexibility allows for a comprehensive approach to E/M coding, regardless of the specific type of service provided.

When selecting the visit level based on total time, it is important to ensure that the encounter is counseling-dominated. While total time can be used as the sole determinant for selecting the visit level, counseling should still play a significant role in the encounter. This ensures that the level of service reflects the complexity and intensity of the counseling provided during the visit.

It is crucial to emphasize that total time should be clinically appropriate and supported by documentation in the medical record. This documentation should clearly demonstrate the medical necessity of the services provided and the time spent on the date of the encounter.

Applying Total Time to E/M Services: An Example

To illustrate the application of total time to specific E/M services, let’s consider an example of an office visit for a counseling-dominated encounter:

In this example, the total time spent during the encounter determines the appropriate level of visit code. For a total time of 25 minutes, a level 3 visit (CPT code 99213) is selected. If the total time is 40 minutes, a level 4 visit (CPT code 99214) would be appropriate. Finally, a total time of 60 minutes would result in a level 5 visit (CPT code 99215).

By applying total time to specific E/M services, healthcare providers can ensure accurate coding and appropriate reimbursement for the care provided. This method promotes comprehensive and patient-centered care while maintaining compliance with coding guidelines. Understanding the nuances of applying total time is essential for optimizing billing practices and promoting quality healthcare delivery.

Caveats and Considerations for Time-based E/M Coding

When utilizing time as the basis for selecting E/M codes, there are important caveats and considerations to keep in mind. Time-based coding should only be used in situations where counseling dominates the encounter, and it should not include time spent on separately reportable services. Documentation should clearly indicate that the services provided were not duplicative and were necessary for the management of the patient. Additionally, it is crucial to note that the professional component of diagnostic tests/studies and activities performed on a separate date should not be included in the total time calculation.

Considerations for Time-based E/M Coding

• Use time-based coding only when counseling dominates the encounter.
• Exclude time spent on separately reportable services.
• Ensure documentation supports the necessity of the provided services.
• Do not include the professional component of diagnostic tests/studies.

Implications of Time-based E/M Coding

When selecting E/M codes based on time, it is important to adhere to the specified guidelines and considerations. Failing to do so can lead to inaccurate coding, reimbursement issues, and potential compliance concerns. By understanding the requirements and accurately documenting the relevant information, healthcare providers can ensure proper medical billing and maintain compliance with coding and documentation guidelines.

Documentation Requirements for Time-based E/M Coding

Updates and Changes to CPT E/M Guidelines

The CPT Editorial Panel has recently implemented updates and changes to the Evaluation and Management (E/M) guidelines, specifically focusing on medical decision making (MDM), history, and exam. These updates aim to enhance the accuracy and specificity of E/M coding and documentation.

One significant change in the new guidelines is the emphasis on a medically appropriate history or exam, rather than relying solely on the number or complexity of problems addressed. This shift highlights the importance of gathering comprehensive patient information to guide medical decision making.

The MDM levels have also been revised to align with those used for office visits. This alignment ensures consistency across different types of E/M services and facilitates accurate code selection for medical billing and reimbursement.

By updating and refining the guidelines, the CPT Editorial Panel aims to streamline the coding and documentation process, making it easier for healthcare providers to accurately capture the complexity of patient encounters and facilitate proper reimbursement.

Changes in CPT E/M Guidelines

| Old Guidelines | Updated Guidelines | |—————————-|———————————| | Emphasized number of | Emphasize medically appropriate | | problems addressed | history or exam | | MDM levels differed across | MDM levels align with office | | different E/M services | visit levels | | | |

The updates in the CPT E/M guidelines bring about significant changes in capturing the complexity of patient encounters. Healthcare providers should familiarize themselves with these updates to ensure compliance with the revised guidelines, thereby facilitating accurate coding, billing, and reimbursement.

Guidelines for MDM Selection in E/M Services

In the process of selecting the appropriate E/M codes for evaluation and management (E/M) services, medical decision making (MDM) plays a crucial role. MDM encompasses several factors that need to be considered, including the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

It is important to note that the final diagnosis alone does not determine the complexity of MDM. Rather, the complexity is determined by the impact of the condition on the management of the patient. The more complex the problems, comorbidities, and data analysis, as well as the higher the risk of complications, morbidity, or mortality, the more intricate the MDM.

In accurately reflecting the level of complexity in the documentation and coding of E/M services, healthcare providers ensure proper reimbursement and compliance with coding guidelines. By carefully evaluating the factors that contribute to MDM, providers can effectively demonstrate the complexity of the problems addressed and the resources required to manage them.

Here is a breakdown of the key considerations for MDM selection in E/M services:

• Number and complexity of problems addressed
• Comorbidities
• Amount and complexity of data reviewed and analyzed
• Risk of complications, morbidity, or mortality
• Final diagnosis and its impact on management
• Complexity of problems and their management

Accurately documenting and coding the appropriate level of MDM is essential for ensuring proper reimbursement and comprehensive representation of the complexity of the patient’s condition. It is crucial to pay attention to the specifics of each patient’s case and make informed decisions based on thorough evaluation and analysis.

Impact of Office Visit CPT Code Changes on Medical Billing

The changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. Healthcare providers must adapt to these changes and understand the documentation requirements and accurate coding necessary to ensure proper reimbursement and reduce the risk of audits.

Accurate coding is crucial in accurately reflecting the level of service provided during the office visit. It ensures that healthcare providers receive accurate reimbursement for their services and helps to reduce the burden of potential audits. Proper documentation and coding also contribute to compliance with coding and documentation requirements, mitigating the risk of financial loss and noncompliance.

It is essential for healthcare providers to familiarize themselves with the new guidelines and understand how to properly document the relevant information. This includes accurately capturing the level of service provided, the complexity of problems addressed, and the time spent on the date of the encounter. By adhering to these documentation requirements, healthcare providers can ensure accurate coding and reimbursement, reducing the risk of claims denials or audits.

Proper documentation not only helps in accurate coding and reimbursement but also simplifies auditing processes, ensuring compliance with coding and documentation requirements. Auditing plays a vital role in the healthcare system, and having the appropriate documentation in place can streamline the auditing process and provide evidence of accurate and compliant billing practices.

Compliance with coding and documentation requirements is essential to avoid potential financial loss and maintain a good standing within the healthcare industry. By accurately documenting and coding office visit services, healthcare providers can demonstrate their commitment to compliance and ensure that they are providing high-quality care to their patients.

In conclusion, the changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. It is crucial for healthcare providers to understand the documentation requirements, accurately code the services provided, and ensure compliance with coding and documentation guidelines. By doing so, healthcare providers can streamline the billing process, reduce the risk of audits, and ensure accurate reimbursement for their services.

Resources for Understanding Office Visit CPT Code Guidelines

When it comes to understanding the guidelines for office visit CPT codes and navigating the changes in E/M coding, healthcare providers can rely on valuable resources provided by reputable organizations such as the American Medical Association (AMA) and the Medicare Learning Network (MLN). These resources offer comprehensive guidance and tools that can help healthcare providers stay up to date and ensure accurate reimbursement.

The CPT Evaluation and Management Services Guidelines, developed by the AMA, provide detailed information on office visit CPT codes, E/M coding principles, and documentation requirements. This resource serves as a comprehensive guide to help healthcare providers understand the intricacies of office visit coding and ensure compliance with the latest guidelines.

The Medicare Learning Network, an educational resource developed by the Centers for Medicare & Medicaid Services (CMS), offers webinars, articles, and other educational materials specifically designed to assist healthcare providers in understanding and implementing the changes in E/M coding. These resources provide practical insights and clarification on the documentation requirements and coding changes specific to office visit CPT codes.

Furthermore, the Medicare Physician Fee Schedule Lookup Tool, available on the CMS website, enables healthcare providers to access reimbursement information for specific office visit CPT codes. This tool allows providers to accurately determine the appropriate reimbursement for their services and ensure proper billing practices.

By leveraging these resources, healthcare providers can enhance their understanding of office visit CPT code guidelines, navigate the complexities of E/M coding, and ensure accurate reimbursement for their services. Staying informed and utilizing these valuable resources is imperative for maintaining compliance and optimizing coding practices.

Understanding the guidelines for office visit CPT codes is essential for accurate medical billing and insurance reimbursement. The recent changes in E/M coding guidelines, particularly regarding time-based code selection and medical decision making, necessitate proper documentation and accurate coding. By comprehensively understanding these guidelines, healthcare providers can maximize their payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

Accurate medical billing is crucial for healthcare practices to receive fair reimbursement from insurance companies. By following the comprehensive guide provided by the American Medical Association (AMA) and the Medicare Learning Network (MLN), healthcare providers can confidently navigate the complexities of office visit CPT codes. This comprehensive guide provides detailed information on selecting the appropriate codes based on medical decision making, time-based code selection, and documentation requirements.

Properly documenting the relevant information and coding accurately not only ensures accurate reimbursement but also reduces the risk of audits and increases compliance. By adhering to the guidelines and best practices outlined in the comprehensive guide, healthcare providers can maintain accurate and compliant medical billing practices, ultimately benefiting both their practice and their patients.

In conclusion, understanding the guidelines for office visit CPT codes is crucial for accurate medical billing and insurance reimbursement. By following the comprehensive guide provided by industry resources such as the AMA and MLN, healthcare providers can navigate the changes in E/M coding and ensure compliance with coding and documentation requirements. This comprehensive understanding of the guidelines allows healthcare providers to optimize payment, minimize audit-related stress, and maintain accurate and compliant medical billing practices.

What are office visit CPT codes?

Office visit CPT codes are evaluation and management (E/M) codes used for billing purposes in family medicine practices and other healthcare settings.

What are the changes to the office visit CPT code guidelines?

The office visit CPT code guidelines have been revised to eliminate the history and physical exam elements, introduce an add-on code for visit complexity, revise the medical decision-making table, and expand the definition of time for E/M services.

How can total time be used for office visit CPT code selection?

Total time, which includes both face-to-face and non-face-to-face interactions, can be used to select the level of service for office visit codes and other E/M services.

What should be included in the calculation of total time for office visit code selection?

Activities such as examining the patient, counseling and educating the patient, reviewing external notes/tests, and documenting in the medical record should be included in the calculation of total time. Ancillary staff time and time related to separately reportable activities should be excluded.

How should total time be documented for office visit code selection?

It is important to document the specific total time spent on activities on the date of the encounter in the patient’s medical record, rather than providing generic time ranges.

What are the documentation guidelines for split or shared visits?

In a split or shared visit scenario, the time personally spent by the physician and other qualified health professional (QHP) should be summed to define total time. Distinct time should be counted, and time spent on activities performed by ancillary staff should not be included.

Can total time be used for other E/M services besides office visits?

Yes, total time can be used to select the level of service for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services.

What are the caveats and considerations for time-based E/M coding?

Time-based coding should only be used when counseling dominates the encounter, and it should not include time spent on separately reportable services. It is important to ensure that the services provided were necessary for the management of the patient.

What updates have been made to the CPT E/M guidelines?

The CPT E/M guidelines have been updated to emphasize the need for a medically appropriate history or exam and to revise the levels of medical decision making to align with office visit levels.

How is medical decision making (MDM) determined in E/M services?

MDM is determined by considering the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

What is the impact of the office visit CPT code changes on medical billing?

The changes in office visit CPT code guidelines have a significant impact on medical billing, requiring proper documentation and accurate coding to ensure accurate reimbursement and reduce the risk of audits.

Where can healthcare providers find resources to understand the office visit CPT code guidelines?

Healthcare providers can refer to resources such as the CPT Evaluation and Management Services Guidelines from the American Medical Association and the Medicare Learning Network for guidance on understanding and implementing the office visit CPT code guidelines.

What is the importance of understanding office visit CPT code guidelines?

Understanding office visit CPT code guidelines is crucial for accurate medical billing, insurance reimbursement, and compliance with coding and documentation requirements.

What is the overall purpose of the comprehensive guide on office visit CPT code guidelines?

The comprehensive guide on office visit CPT code guidelines provides healthcare providers with a thorough understanding of the guidelines, enabling them to maximize payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

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What Are CPT Codes?

• Where Codes Are Used
• Codes and Services
• Coding Errors

HCPCS Codes

Frequently asked questions.

Current Procedural Terminology (CPT) codes are numbers assigned to each task and service that you can get from a healthcare provider. For example, a routine check-up or a lab test has a code attached to it.

CPT codes are used to track and bill medical, surgical, and diagnostic services. Insurers use CPT codes to determine how much money to pay providers.

The same CPT codes are used by all providers and payers to make the billing process consistent and to help reduce errors.

This article will go over what CPT codes are used for and what problems you might encounter related to CPT codes on your medical or insurance records.

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A CPT code is usually a five-digit numeric code. However, some CPT codes are four numbers and one letter. A CPT code has no decimal points.

Some CPT codes are only used occasionally and some are not really used at all. Other CPT codes are used frequently. For example, 99213 and 99214 are codes for general office visits, usually to address one or more new concerns or complaints, or to follow up on one or more problems from a previous visit.

The American Medical Association (AMA) develops, maintains, and has copyrighted the CPT codes that are used today all over the world. These codes can change as healthcare changes, and new codes can be made and assigned to new services.

Current CPT codes can also be revised and unused codes thrown out. Thousands of CPT codes are used and updated every year.

Limitations of CPT Codes

While they are meant to help make the billing process in healthcare more uniform, the existence of CPT codes does not mean that everyone defines a healthcare service the same way.

CPT codes also do not ensure that different healthcare providers will get paid the same amount for the same service because payment is outlined in the contracts between providers and insurers.

For example, Healthcare Provider A may perform a physical check-up (99396) and be paid $100 by your insurance company. However, if you went to Healthcare Provider B, the payment for that same CPT code might only be $90.

Verywell / Laura Porter

Types of CPT Codes

There are several categories of CPT codes:

• Category I: Procedures, services, devices, and drugs (including vaccines )
• Category II: Performance measures and quality of care (for example, patient follow-up)
• Category III: Services and procedures using emerging technology (these codes are usually temporary while the service or procedure is still fairly new)
• PLA codes: Used for lab testing

List of CPT codes

Here are some examples of CPT codes:

• 99214 can be used for an office visit
• 99397 can be used for a preventive exam if you are over age 65
• 90658 can be used for the administration of a flu shot
• 90716 can be used for the administration of the chickenpox vaccine (varicella)
• 12002 can be used when a healthcare provider stitches up a 1-inch cut on your arm
• 87635 can be used when you're given a COVID-19 test

Bundled Services

Bundled services are a single CPT code that describes several services that are performed together.

For example, if you break your arm and get an X-ray and a cast, these services might be bundled under one code for billing.

How CPT Codes Are Used

CPT codes directly affect how much a patient will pay for the medical care they receive.

Provider offices, hospitals, and other medical facilities are strict about how CPT coding is done. They hire professional medical coders or coding services to make sure that services are coded correctly.

Initial Coding

Your healthcare provider or their office staff will usually start the coding process.

If they use paper forms, they will list which CPT codes apply to your visit. If they use an electronic health record (EHR) during your visit, it will be noted in that system. These systems usually let staff call up codes based on the service name.

What’s the Difference Between a CPT Code and a ICD Code?

CPT codes have different uses than ICD codes . CPT codes identify the services provided to a patient, and ICD codes identify diagnoses. The CPT code system is managed by the American Medical Association, while the ICD code system is managed by the World Health Organization. 

Verification and Submission

After you leave the office, medical coders and billers examine your records. They make sure the correct CPT codes are assigned.

Next, the billing department submits a list of your services to your insurer or payer. Most healthcare providers store and transfer this information digitally, but some are still done by mail or fax.

Claim Processing

Your health plan or payer uses CPT codes to process the claim. They will decide how much to pay your provider and how much you will owe for the services that you got.

Health insurance companies and government officials use coding data to predict future health care costs for the patients in their systems.

State and federal government analysts use coding data to track trends in medical care. This information helps to plan and budget for Medicare and Medicaid.

Where You Will See CPT Codes

You'll see CPT codes in many different documents that you'll get as you move through the healthcare system.

Discharge Paperwork

When you are done with an appointment or are discharged from a healthcare facility, you will get some paperwork to take home with you. It usually includes a summary of the services you had, including the codes for those services.

The five-character codes are usually CPT codes. There are also other codes on that paperwork, like ICD codes that indicate a diagnosis (which may have numbers or letters, and usually decimal points).

When you get a medical bill, it will have a list of the services you received. Next to each service will be a five-digit code—usually, it's the CPT code.​

Explanation of Benefits

When you receive an explanation of benefits (EOB) from your payer, it will show how much of the cost of each service was paid on your behalf. Each service will be matched with a CPT code.

Matching CPT Codes to Services

If you're looking at your healthcare providers' and insurance billing process, you might want to know what all the codes mean.

However, CPT codes are copyrighted by the AMA and they charge a fee to use them. That means that you will not find a full list of CPT codes with explanations online for free.

That said, the AMA does provide consumers with a way to look up the CPT codes. Here's how to find out what a CPT code means:

• Do a CPT code search on the AMA website . You will have to register (for free). You are limited to five searches per day. You can search by a CPT code or use a keyword to see what the code for a service might be.
• Contact your healthcare provider's office and ask them to help you match the CPT codes and services.
• Contact your payer's billing department and ask them to help you with the CPT codes.

You can use the same steps to look up bundled codes.

Preventing Incorrect Coding

Understanding CPT codes can help you make sure that your hospital bill is correct and catch any billing errors—which do happen often. Some patient advocacy groups say that nearly 80% of bills for medical care contain minor errors.

These simple mistakes can have a big impact on your wallet. In fact, the wrong CPT code can mean that your insurance will not cover any of the costs.

Always review your bill carefully and compare it with your EOB to check for mistakes. It's not uncommon for healthcare providers or facilities to code for the wrong type of visit or service (typographical errors).

There are also fraudulent practices like "upcoding," which is when you are charged for a more expensive service than the one you got. On the other hand, "unbundling" is when bundled services or procedures are billed as separate charges.

If you come across something in your medical bill that doesn't add up, call your provider's office. It could be a simple mistake that the billing department can fix.

CPT codes are similar to codes from the Healthcare Common Procedure Coding System (HCPCS). If you use Medicare, you'll see HCPCS codes in your paperwork instead of CPT codes.

HCPCS codes are used and maintained by the Centers for Medicare & Medicaid Services (CMS). They are used to bill Medicare, Medicaid, and many other third-party payers.

HCPCS Code Levels

• Level I codes are based on CPT codes and are used for services and procedures that are offered by healthcare providers.
• Level II codes cover healthcare services and procedures that are not performed by healthcare providers.

HCPCS level II codes start with a letter and have four numbers. They may also have extra modifiers—either two letters or a letter and a number. Examples of items billed with level II codes are medical equipment, supplies, and ambulance services .

HCPCS level II code lists can be found on the CMS website . Level I codes, however, are copyrighted by the AMA just like CPT codes.

CPT codes are combinations of letters and numbers that match up with healthcare services and supplies. The AMA developed CPT codes to make sure that all healthcare providers have a uniform system for reporting the services they give to patients.

When you visit a healthcare facility, your provider uses CPT codes to let your insurer or payer know which services you got from them. The insurer or payer then reimburses the provider based on the CPT codes. You can see the codes on your discharge paperwork, bills, and benefit statements.

It's a good idea to check the codes when you receive a bill or statement. Your provider or the coder can sometimes make errors and if they're not fixed, you could pay more than you should have to.

Healthcare Common Procedure Coding System (HCPCS) codes are used by the Centers for Medicare and Medicaid Services (CMS) to bill Medicare, Medicaid, and other third-party payers.

HCPCS codes are separated into two levels of codes:

• Level I: Based on CPT codes, these are used for services or procedures often provided by healthcare providers.
• Level II: These codes cover health care services or procedures that healthcare providers do not offer. Examples include medical equipment, supplies, and ambulance services.

An encounter form keeps track of the diagnosis and procedure codes that are recorded when a patient visits a provider's office. The purpose of the form is to make sure the billing is correct and a receipt can be offered to the patient after the visit.

The six sections of CPT codes are Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine. Each of the six sections also has sections within it that offer more detail about services.

Some of the most frequently used CPT codes are:

99201-05 (New Patient Office Visit)

99211-15 (Established Patient Office Visit)

99221-23 (Initial Hospital Care for New or Established Patient)

99231-23 (Subsequent Hospital Care)

99281-85: (Emergency Department Visits)

9241-45 (Office Consultations)

The CPT codes are currently used in over 60 countries.

American Medical Association. CPT® purpose & mission .

American Medical Association. CPT® overview and code approval .

American Medical Association. New CPT code for COVID-19 testing: What you should know .

Centers for Disease Control and Prevention. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) .

Kaiser Family Foundation.  Studies find high rates of errors on medical billing .

Centers for Medicare & Medicaid Services. HCPCS coding questions .

American Association of Professional Coders. What is CPT ® ?

Meditec. Commonly used CPT codes in medical coding .

American Medical Association. CPT international .

By Trisha Torrey  Trisha Torrey is a patient empowerment and advocacy consultant. She has written several books about patient advocacy and how to best navigate the healthcare system. 

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Annual Wellness Visit | CPT codes

2023 Annual Wellness Visit CPT Codes: G0402, G0438, G0439

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January 25th, 2023 | 8 min. read

Daniel Godla

Founder and CEO of ThoroughCare

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Understanding the billing codes for Medicare Annual Wellness Visits (AWVs) can provide a better idea of what is expected, both by the patient and by the payer. Understanding billing codes may also help you project revenues and optimize your staff’s capacity .

At ThoroughCare , we’ve worked with clinics and physician practices nationwide to help them streamline and capture Medicare reimbursements. Our software solution assists with the rules and regulations for AWVs while also tracking all activities related to providing the program and easing the difficulties of billing.

What are Annual Wellness Visits?

Annual Wellness Visits are free for anyone covered by Medicare Part B and include a yearly assessment of a patient’s health and overall well-being. They are designed not as a yearly physical examination, but as a critical care marker that bridges gaps in the yearly physical exam while developing and updating a patient’s personalized plan of care.

That personalized care plan is designed to help prevent disease and disability and is based on the patient’s current health and determined risk factors. The overall goal is to establish a record of the patient’s physical and mental well-being for the purpose of preventive health planning .

AWVs Include:

• A health risk assessment (HRA)
• A review and update of medical and family history
• A review of current providers, prescriptions/medications, and durable medical equipment suppliers
• Height, weight, blood pressure, BMI, and other routine measurements
• Personalized health advice, health education, and preventative counseling
• A list of identified risk factors, current medical and mental health conditions, and recommended treatment options
• A cognitive impairment screening
• A five to 10-year screening schedule for appropriate preventive services
• A review of the patient’s functional ability and level of safety, including screening for hearing impairments, risk of falling, activities of daily living, and level of home safety
• Identification of patients at risk for alcohol, tobacco, and opioid abuse
• Advance care planning

There are three types of wellness visits : Initial Preventive Physical Examination (IPPE), an Initial Annual Wellness Visit, and the Subsequent Annual Wellness Visit. Each entails a different billing code as well as specific qualifiers for each program.

• Initial Preventive Physical Examination: Patients may only receive this benefit within the first 12 months of their Medicare enrollment . Commonly referred to as the “welcome to Medicare visit,” it is considered a once in a lifetime assessment and after the initial eligibility period, the patient cannot receive an IPPE. It is also dependent on the HRA .
• Initial Annual Wellness Visits : Similar to an IPPE, except it is available to a patient after 11 months of Medicare enrollment . This is for patients that miss their window for an IPPE. However, if the patient does complete an IPPE, they must still complete the Initial Annual Wellness Visit. This screening also includes an optional cognitive exam and end-of-life planning. 
• Subsequent Annual Wellness Visit: Is the yearly follow-up to an Initial Annual Wellness Visit . Eleven full months after the Initial Annual Wellness Visit, a patient can attend these visits to modify and maintain their preventive care plan, based on how their health is at any given time. 

As the patient’s health evolves over time, a doctor may use the Subsequent Annual Wellness Visit to guide them toward other Medicare preventive programs, such as Chronic Care Management (CCM) , Behavioral Health Integration (BHI) , or Remote Patient Monitoring (RPM) . 

Identify risk:   ThoroughCare helps clinicians deliver AWVs and close gaps in care

Billing Medicare Annual Wellness Visits

Five items are required when submitting a claim through Centers for Medicare & Medicaid Services (CMS) :

• A CPT Code for the specific type of AWV provided
• An ICD-10 code for a general adult medical examination (Z00.00)
• Date of service
• Place of service (most office in-office or telehealth)
• Submit National Provider Identifier (NPI) number

It is helpful to know the care manager assigned to a patient in case of an audit.

Three Steps to Bill for AWVs :

• Verify CMS requirements were met
• Submit claims to CMS annually
• Determine there are no conflicting billing codes

2023 CPT Codes for Annual Wellness Visits

See 2024 reimbursement rates here .

The types of AWVs are reflected in the CPT codes. The crucial qualifying determinant is when a certain AWV can be provided and billed.

AWVs for Federally Qualified Health Centers (FQHC) and Advance Care Planning (ACP)

As shown in the chart above, FQHC are able to bill for AWVs, although they utilize additional codes.

In addition to the standard CPT codes associated with AWVs, FQHC may use a special add-on code (G0468) that will allow them to receive additional reimbursement. For example, if an FQHC were to provide an IPPE, the clinic would bill for G0402 + G0468 for a total average reimbursement of $322. This coding indicates to CMS that the service is being provided through an FQHC. The good news is that these organizations receive much higher average reimbursement rates

Advance care planning (ACP) is not a type of AWV , but it can play a meaningful part in the program. 

ACP is a formal process to understand the patient’s preferences for potential and future medical care, such as end-of-life planning, a living will, and power of attorney. It is an opportunity to craft a patient-centered care plan and an AWV drives just that opportunity. Providers often complete an ACP during an AWV. 

ACP is fully covered for patients under Medicare Part B if it is conducted during the AWV. It is a free service that is an optional element of AWVs. Favorably, it is reimbursable for your practice and can be billed in concurrence with an AWV using CPT code 99497 for the first 30 minutes and 99498 for subsequent 30-minute billing.

Streamline Medicare Annual Wellness Visits

ThoroughCare   offers end-to-end workflow for Annual Wellness Visits.

We simplify the process and help providers engage patients to get their most relevant health information. Guided interviews help ask the right questions and ensure all service requirements are met. ThoroughCare includes digital solutions, such as:

• An interactive health risk assessment
• Screening tools, such as ADL, CAGE, DAST-10, GAD-7, MDQ, PAC, PHQ-2, and a mini cognitive exam
• A care gaps summary with recommended interventions
• A full report of Personalized Prevention Plan Services
• Comprehensive care planning tools
• Automated CPT code assignment for accurate billing

Reimbursement rates are based on a national average and may vary depending on your location.   Check the Physician Fee Schedule   for the latest information.

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Healthcare Common Procedure Coding System (HCPCS)

Each year in the U.S., health care insurers process over 5 billion claims for payment. Standardized coding systems are essential so Medicare and other health insurance programs can process claims in an orderly and consistent manner. HCPCS is divided into 2 main subsystems — Level I and Level II.

HCPCS Level I : Comprised of Current Procedural Terminology (CPT ® ), a numeric coding system maintained by the American Medical Association (AMA). 

• CPT ® is a uniform coding system consisting of descriptive terms and identifying codes used primarily to identify medical services and procedures furnished by physicians and other health care professionals for which they bill public or private health insurance programs. 
• The AMA annually republishes and updates CPT ® codes.
• CPT ® codes consist of 5 numeric digits.
• Contact the AMA for issues related to the application of HCPCS Level I CPT® codes for physicians.

HCPCS Level II : A standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT® codes, such as ambulance services or durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.

• Medicare and other insurers cover a variety of services, supplies, and equipment that aren't identified by CPT® codes. The HCPCS Level II codes were established so providers and suppliers can submit claims for these items. 
• HCPCS Level II codes (also known as alpha-numeric codes) consist of a single alphabetical letter followed by 4 numeric digits. 
• The HCPCS Level II coding system began in the 1980s.
• In 2003, under 42 CFR 414.40(a) , the HHS Secretary delegated authority to CMS to establish and maintain uniform national definitions of services, codes to represent services, and payment modifiers to the codes.
•  For questions about HCPCS Level II, contact [email protected] .

Medicare Electronic Application Request Information System (MEARIS™)

Visit MEARIS™ to submit HCPCS Level II coding application.

• Anyone may submit a request to modify the HCPCS Level II national code set.
• Quarterly drug and biological product applications.
• Biannual non-drug and non-biological items and services applications.
• Drug and biological products: The first business day of each quarter (January, April, July, and October)
• Non-drug and non-biological items and services: The first business day of January and July

B1 2024 HCPCS LEVEL II PUBLIC MEETING MATERIALS

CMS is announcing the publication of its First Biannual (B1) 2024 HCPCS Public Meeting Agendas for its May 28 - 30, 2024, Virtual HCPCS Public Meeting. The agendas are available at: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/HCPCSPublicMeetings .

CMS recommends interested parties refer to the Guidelines for Participation in HCPCS Public Meetings for B1 2024, which are available at: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/HCPCSPublicMeetings .

The guidelines contain important and useful information, such as instructions for registering to attend the B1 2024 HCPCS Public Meeting as a primary or a 5-minute speaker; instructions for accessing the meeting as an attendee; deadlines for registration and materials submission; and tips for helping CMS conduct a productive meeting.

The deadline to register as a speaker is Friday, May 17, 2024, at 5:00 p.m., eastern time (ET). All speakers must register online, identify as a primary speaker or a 5-minute speaker, and provide the requested contact information at: [email protected] .  Primary speakers are permitted to submit written presentation materials, which are also due no later than Friday, May 17, 2024, at 5:00 p.m., ET.

Please access the virtual public meeting through the Zoom information below: 

• Zoom link: https://cms.zoomgov.com/s/1605121459  
• Passcode: 327890
• Join by telephone: 833 435 1820 (Toll Free) or 833 568 8864 (Toll Free) 
• Webinar ID: 160 512 1459

To view older announcements, visit HCPCS Level II Archive .

Get Email Updates

Sign up to our HCPCS Level II Updates Listserv to get the most current and accurate information about HCPCS Level II codes. Signing up is quick and easy!

Related Links

• Alpha-Numeric HCPCS Quarterly File (2017 - 2020)
• Average Sales Price (ASP) Pricing Files
• DMEPOS Fee Schedule Files
• HCPCS Quarterly File Update (2020 - Present)
• Medicare Contractor for Pricing, Data Analysis and Coding (PDAC) of HCPCS Level II

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