E & M CPT code - Important points to follow

Evaluation and management (E/M) tips

Key points to remember


Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT

code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a

lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific

level of service is billed. Documentation should support the level of service reported. The service should be documented

during, or as soon as practicable after it is provided in order to maintain an accurate medical record.
The key components (elements of service) of evaluation & management (E/M) services are:

1. History
2. Examination
3. Medical decision-making

When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-

to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to

qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.

Tips pertaining to different types of E/M services can be located by accessing the links in the table below:


CPT code range

Type of E/M service 

99201-99205 Office or other outpatient E/M services for new patients
99211-99215  Office or other outpatient E/M services for established patients
99221-99223 Initial hospital care E/M services
99231-99233 Subsequent hospital care E/M services
96150-96154, G0425-G0427 Telehealth Services external pdf file


Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:

1. History,
2. Examination, and
3. Medical decision-making.

When billing office or other outpatient services for new patients, all 3 key components must be fully documented in order to

bill. When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter

(face-to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to

qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.

CPT codes and requirements

99201 - 10 minutes (average)

• Problem focused history. Documentation needed:
• Chief complaint
• Brief history of present illness
• Problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system
• Medical decision making that is straightforward. Documentation needed (2 of 3 below must be met or exceeded):
• Minimal number of diagnoses or management options
• None or minimal amount and/or complexity of data to be reviewed
• Minimal risk of significant complications, morbidity and/or mortality


99202 - 20 minutes (average)
• Expanded problem focused history. Documentation needed:
• Chief complaint
• Brief history of present illness
• Problem pertinent review of systems
• Expanded problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ  system(s)
• Medical decision making that is straightforward. Documentation needed (2 of 3 below must be met or exceeded):
• Minimal number of diagnoses or management options
• None or minimal amount and/or complexity of data to be reviewed
• Minimal risk of significant complications, morbidity and/or mortality


99203 - 30 minutes (average)
• Detailed history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Extended review of systems
• Pertinent past, family and/or social history
• Detailed examination. Documentation needed:
• Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or   organ system(s)
• Medical decision making that is of low complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Limited number of diagnoses or management options
• Limited amount and/or complexity of data to be reviewed
• Low risk of significant complications, morbidity and/or mortality


99204 - 45 minutes (average)
• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family and/or social history
• Comprehensive examination. Documentation needed:
• A general multi-system examination OR complete examination of single organ system and other symptomatic or related body  area(s) or 8 or more organ system(s)
• Medical decision making that is of moderate complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Multiple number of diagnoses or management options
• Moderate amount and/or complexity of data to be reviewed
• Moderate risk of significant complications, morbidity and/or mortality


99205 - 60 minutes (average)
• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family and/or social history
• Comprehensive examination. Documentation needed:
• A general multi-system examination OR complete examination of single organ system and other symptomatic or related body  area(s) or 8 or more organ system(s)
• Medical decision making that is of high complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Extensive number of diagnoses or management options
• Extensive amount and/or complexity of data to be reviewed
• High risk of significant complications, morbidity and/or mortality






Evaluation & management tips: Office or other outpatient services, established patient

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:
1. History
2. Examination
3. Medical decision-making.

When billing office or other outpatient services for established patients, 2 of the 3 key components must be fully

documented in order to bill (other than 99211). When counseling and/or coordination of care dominates (more than 50%) the

physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be   documented in the medical record.


Current Procedural Terminology® (CPT) codes and requirements

99211 - 5 minutes (average)
• Patient presenting with minimal problems
• 3 components not required

99212 - 10 minutes (average)
• Problem focused history. Documentation needed:
• Chief complaint
• Brief history of present illness
• Problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system
• Medical decision making that is straightforward. Documentation needed (2 of 3 below must be met or exceeded):
• Minimal number of diagnoses or management options
• None or minimal amount and/or complexity of data to be reviewed
• Minimal risk of significant complications, morbidity and/or mortality

99213 - 15 minutes (average)
• Expanded problem focused history. Documentation needed:
• Chief complaint
• Brief history of present illness
• Problem pertinent review of systems
• Expanded problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
• Medical decision making that is of low complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Limited number of diagnoses or management options
• Limited amount and/or complexity of data to be reviewed
• Low risk of significant complications, morbidity and/or mortality

99214 - 25 minutes (average)
• Detailed history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Extended review of systems
• Pertinent past, family and/or social history
• Detailed examination. Documentation needed:
• Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or  organ system(s)
• Medical decision making that is of moderate complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Multiple number of diagnoses or management options
• Moderate amount and/or complexity of data to be reviewed
• Moderate risk of significant complications, morbidity and/or mortality

99215 - 40 minutes (average)
• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history
• Comprehensive examination. Documentation needed:
• A general multi-system examination OR complete examination of single organ system and other symptomatic or related body area(s) or 8 or more organ system(s)
• Medical decision making that is of high complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Extensive number of diagnoses or management options
• Extensive amount and/or complexity of data to be reviewed
• High risk of significant complications, morbidity and/or mortality






Evaluation & management tips: Initial hospital care, new or established patient

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:
1. History,
2. Examination, and
3. Medical decision-making.
When billing initial hospital care, all 3 key components must be fully documented in order to bill. When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (at the bedside and floor/unit time in the hospital), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.
CPT codes and requirements

99221 - 30 minutes (average)
• Detailed OR comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Detailed - Extended review of systems; Pertinent past, family and or social history
• Comprehensive - Complete review of systems; Complete past, family, and social history
• Detailed OR comprehensive examination. Documentation needed:
• Detailed - Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body  area(s) or organ system(s)
• Comprehensive - General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or 8 or more organ system(s)
• Medical decision making that is straightforward OR of low complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Straightforward - Minimal number of diagnoses or management options; None or minimal amount and/or complexity of data to  be reviewed; Minimal risk of significant complications, morbidity and/or mortality
• Low complexity - Limited number of diagnoses or management options; Limited amount and/or complexity of data to be reviewed; Low risk of significant complications, morbidity and/or mortality

99222 - 50 minutes (average)
• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history
• Comprehensive examination. Documentation needed:
• General multi-system examination OR complete examination of a single organ system and other symptomatic or related body  area(s)or 8 or more organ system(s)
• Medical decision making that is moderate complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Multiple number of diagnoses or management options
• Moderate amount and/or complexity of data to be reviewed
• Moderate risk of significant complications, morbidity and/or mortality

99223 - 70 minutes (average)
• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history
• Comprehensive examination. Documentation needed:
• General multi-system examination OR complete examination of a single organ system and other symptomatic or related body  area(s)or 8 or more organ system(s)
• Medical decision making that is of high complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Extensive number of diagnoses or management options
• Extensive amount and/or complexity of data to be reviewed
• High risk of significant complications, morbidity and/or mortality