Booklet

Evaluation and Management Services Guide

CPT codes, descriptions, and other data only are copyright 2022 American Medical Association. All Rights Reserved.
Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are
not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly
or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not
contained herein.

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Table of Contents
What’s Changed? 3

Office or Outpatient E/M Visits 4

Critical Care Services 4

Concurrent Critical Care Services: Different Specialties 4
Concurrent Critical Care Services: Individuals in the Same Specialty &
Same Group (Follow-Up Care) 5
Critical Care & Other Same-Day E/M Visits 5
Critical Care Services & Global Surgery 6

Initial Hospital Inpatient or Observation Care 6

Observation Care Following Initiation of Observation Services 6
Prolonged Hospital Inpatient or Observation Care Services 7
Initial Hospital Inpatient or Observation Care on Day Following Visit 7
Initial Hospital Inpatient or Observation Care and Discharge on Same Day 7

Home or Residence Services 8

Prolonged Home or Residence E/M Visits 9

Nursing Facility Services 9

Prolonged Services 9
Prolonged Office or Outpatient E/M Visits 9
Prolonged Other E/M Visits 11
Prolonged NF Services 12

Split (or Shared) E/M Services 12

General Principles of E/M Documentation 15

Common Sets of Codes Used to Bill for E/M Services 16

HCPCS 16
ICD-10-CM 16
ICD-10-PCS 16

Choosing the Code That Characterizes Your Services 17

Patient Type 17
Setting of Service 17
Level of E/M Service You Provide the Patient 17

Other Considerations 18
Chronic Pain Management 18
Consultation Services 19
Teaching Physician Services 20
Telehealth Services 20

Resources 21

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What’s Changed?
We made significant updates to the language, order, and formatting of this product to better meet provider
needs and improve understanding.
• 2023 Medicare Physician Fee Schedule Final Rule

• Change Request (CR 13004), Pub. 100-04 Medicare Claims Processing, R11732CP
○ New home or residence services category and billing instructions (page 8)

○ Domiciliary, rest home (boarding home), or custodial care and home visits into a single code
set (page 9)

• Change Request (CR 13064), Pub. 100-04 Medicare Claims Processing, R11842CP
○ Updates to outpatient and other E/M services (pages 4-18)

• Hospital inpatient and observation visits merged into a single code set (page 6)

• New descriptor times (page 11)

• Choice of medical decision making or time to select visit level, except for visits that aren’t
timed, like emergency department visits (page 17

• Eliminated using history and exam to decide visit level and added a necessity for a
medically appropriate history or exam or both (page 18)

• Revised CPT E/M guidelines for levels of medical decision making (page 18)

• Change Request (CR 13065), Pub. 100-04 Medicare Claims Processing, R11828CP
○ Updates to reporting split (or shared) E/M visits (page 12)

○ Clarification for reporting threshold time for the add-on code (CPT code 99292) for critical
care services that aren’t split (or shared) (page 13)

• Change Request (CR 12982), Pub. 100-04 Medicare Claims Processing, R11708CP
○ Updates to billing telehealth services

• Use modifier 95 for telehealth services (page 20)

• New HCPCS codes G0316, G0317, G0318 for prolonged telehealth services (page 20)

Substantive content updates are in dark red.

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Office or Outpatient E/M Visits

For dates of service in 2023, use the revised CPT codes for Other E/M services (except for prolonged
services). This includes:
● Hospital inpatient and observation visits merged into a single code set
● New descriptor times, where relevant
● Revised CPT E/M guidelines for levels of MDM

Prolonged Office/Outpatient E/M Visits

When you select office or outpatient E/M visit level using time, report prolonged office or outpatient E/M visit
time using HCPCS add-on code G2212 (Prolonged office or outpatient E/M services). For more information
see Prolonged Services.

Critical Care Services

CPT Codes 99291 & 99292
Beginning January 1, 2022, use the AMA CPT language for the definition of critical care visits (CPT codes
99291 and 99292):
● Your direct delivery of care to a critically ill or injured patient when 1 or more vital organ systems are
acutely impaired,
● A probability of imminent or life-threatening deterioration of the patient’s condition exists, and
● Your high complexity decision making to treat single or multiple vital organ system failure or to prevent
further life-threatening deterioration of the patient’s condition that requires your full attention

During time spent providing critical care services, you can’t provide services to any other patient. Bundled
services that are included by CPT in critical care services and therefore not separately payable include
interpretation of cardiac output measurements, chest X rays, pulse oximetry, blood gases and collection and
interpretation of physiologic data (for example, ECGs, blood pressures, hematologic data), gastric intubation,
temporary transcutaneous pacing, ventilator management, and vascular access procedures. See CR 12543.

When you provide 30-74 minutes of critical care services to a patient on a given day, report CPT code 99291.
● Only use CPT code 99291 once per date even if the time you spend isn’t continuous on that date
● Report CPT code 99292 for additional 30-minute time increments you provide to the same patient
● Don’t report 99292 until you spend 104 minutes (74 + 30 = 104 minutes) with the patient
● You may add non-continuous time for medically necessary critical care services

Concurrent Critical Care Services: Different Specialties

Concurrent care is when more than 1 individual provides services that are more extensive than consultative
services at the same time. We cover the reasonable and necessary services of each individual providing
concurrent care when each plays an active role in the patient’s treatment.

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You may provide critical care services concurrently with more than 1 individual from more than 1 specialty to
the same patient on the same day if the services meet the definition of critical care and aren’t duplicative.

Concurrent Critical Care Services: Individuals in the Same Specialty & Same Group
(Follow-Up Care)
CPT Codes 99291 & 99292
When you provide the entire initial critical care service and report CPT code 99291, any provider in the same
specialty and the same group providing care concurrently to the same patient on the same date should report
their time using the code for additional time intervals (CPT code 99292).
● These providers shouldn’t report CPT code 99291 more than once for the same patient on the
same date
● When 1 provider begins the initial critical care service but doesn’t meet the time needed to report
CPT code 99291, another provider in the same specialty and group can continue to deliver critical
care to the same patient on the same date
○ Combine the total time providers spent to meet the required time to bill CPT code 99291
○ Once you meet the cumulative time to report critical care service CPT code 99291, only an
individual in the same specialty and group can report CPT code 99292 when they provide an
additional 30 minutes of critical care services to the same patient on the same date (74 minutes +
30 minutes = 104 total minutes)
○ The time spent on critical care visits must be medically necessary, and each visit must meet the
definition of critical care

Tip: There are different billing rules when the critical care services are split between a physician and
NPP. See Split (or Shared) Services.

Critical Care & Other Same-Day E/M Visits

Starting February 15, 2022, you may bill hospital E/M visits the same day as critical care services in certain
circumstances. See CR 12543.

For other E/M services billed for the same patient on the same date as a critical care service, document that
the service is:
● Provided before the critical care service at a time when the patient didn’t require critical care
● Medically necessary
● Separate and distinct, with no duplicative elements from the critical care service provided later in
the day

Use modifier 25 (same-day significant, separately identifiable E/M service) on the claim when you report critical
care services unrelated to the service or procedure that you perform on the same day. You must also document
the medical record with the relevant criteria for the respective E/M service you’re reporting.

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Critical Care Services & Global Surgery

If you perform critical care unrelated to the surgical procedure during a global surgical period, you may get
separate payment for the services. Medicare may pay for preoperative and postoperative critical care in
addition to the procedure if:
● The patient is critically ill and requires your full attention
● The critical care is above and beyond, and unrelated to the specific anatomic injury or general surgical
procedure performed (like, trauma or burn cases)

When a critical care service is unrelated to the surgical procedure, use modifier FT on your claim. Modifier FT
describes an unrelated E/M visit:
● On the same day as another E/M service, or
● During a global procedure (preoperative period or postoperative period), or on the same day as
the procedure
● Also report modifier FT if you provide 1 or more unrelated E/M visits on the same day as the
critical care CPT code

If the surgeon fully transfers care to you and the critical care is unrelated, use the appropriate modifier to show
the transfer of care. Surgeons will use modifiers 54 (surgical care only) or 55 (postoperative management only)
on their claims. When you accept the transfer of care, add both modifier 55 and modifier FT to your claim.
Medical record documentation must support the claims.

Initial Hospital Inpatient or Observation Care

Observation Care Following Initiation of Observation Services
CPT Codes 99221-99223, 99231-99236
Starting January 1, 2023, bill for hospital inpatient and observation care services using the revised
Hospital Inpatient or Observation Care services code set (CPT codes 99221-99223, 99231-99239). For
patients admitted and discharged on the same date of service, bill hospital inpatient or observation care
(including admission or discharge) using CPT codes 99234-99236.

The time you count toward hospital inpatient or observation care codes is per day. Per day (also called the
encounter date) means the calendar date. When you use MDM or time for code selection, a continuous service
that spans the transition of 2 calendar dates is a single service.
● Report the date the patient encounter begins
● If you provide a continuous service (before and through midnight), you may apply all of the time to
the date of the service you report (the calendar date the encounter starts).
● You may only bill 1 of the hospital inpatient or observation care codes per calendar date for:
○ An initial visit
○ A subsequent visit
● Select a code that includes all of the services (including admission and discharge) you provide on
that date

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The treating provider bills for the observation care codes. Individuals who provide consultations, other
evaluations, or services while the patient is getting hospital outpatient observation services must bill using the
appropriate outpatient service codes.

When billing an initial hospital inpatient or observation care service, a transition from observation status to
inpatient status isn’t a new stay. Medicare Administrative Contractors (MACs) will only pay you for 1 hospital
visit per day for the same patient, even if the problems you treat aren’t related.

Tip: In some cases, you may bill a prolonged code in addition to the Hospital Inpatient or Observation
Care services base code. You may count time you spend on the same day with the same patient in
multiple settings or time you spend on a patient who transitions between outpatient and inpatient status
toward the Hospital Inpatient or Observation Care services base code and a prolonged code (if it
applies).

Prolonged Hospital Inpatient or Observation Care Services

HCPCS Code G0316
Starting January 1, 2023, report prolonged services for certain hospital inpatient or observation care visits
using HCPCS code G0316. You can report prolonged services when you use time to select your visit level, and
you exceed your total time for the highest-level visit by 15 or more minutes on medically necessary services.
See Prolonged Services for detailed reporting instructions.

Initial Hospital Inpatient or Observation Care on Day Following Visit

CPT Codes 99221-99223, 99231-99236, 99238 & 99239
MACs pay both visits if you see a patient in the office on 1 day, and they’re admitted to the hospital as an
inpatient or get observation care on the next day. This applies even if fewer than 24 hours has elapsed
between the visit and the admission for hospital inpatient or placement in observation care.

Initial Hospital Inpatient or Observation Care and Discharge on Same Day

CPT Codes 99221-99223, 99231-99236, 99238 & 99239
Bill both hospital inpatient and observation care coding as follows:
● When you admit a patient to inpatient hospital or observation care for less than 8 hours on
the same day, report the Initial Hospital Inpatient or Observation Care from CPT code range
99221 - 99223
● Don’t report Hospital Inpatient or Observation Discharge Day Management services, (CPT
codes 99238 or 99239) if the patient is in observation care for less than 8 hours
● When you admit a patient to inpatient hospital or observation care and discharge them on a
different date, report an Initial Hospital Inpatient or Observation Care from CPT code range
99221 - 99223 and a Hospital Inpatient or Observation Discharge Day Management service,
CPT code 99238 or 99239
● When you admit a patient to inpatient hospital or observation care for 8 or more hours but less
than 24 hours and discharge them on the same calendar date, report Hospital Inpatient

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or Observation Care services (including admission and discharge services), CPT code range
99234 - 99236

You must satisfy the E/M documentation guidelines for admission to and discharge from inpatient observation
or hospital care. You must also meet and document the guidelines for history, examination, and MDM in the
medical record.

Tip: Per the CPT code descriptors, Initial Hospital Inpatient or Observation Care services requires a
medically appropriate history and examination, but won’t be used to select your visit level. If you’re
working in hospitals, be aware of the documentation you need to bill under the Physician Fee Schedule
(PFS), other payment systems, or Conditions of Participation.

Table 1 shows billing based on hospital length of stay and discharge date.

Table 1. Billing Hospital Length of Stay and Discharge Date

Discharged On Hospital Length of Stay Codes to Bill

Less than 8 hours Initial hospital services only*

Same calendar date as
admission or start of observation
8 or more hours Same-day admission/discharge*

Less than 8 hours Initial hospital services only*

Different calendar date than
admission or start of observation Initial hospital services* +
8 or more hours
discharge day management
*Plus prolonged inpatient/observation services, if applicable.

Home or Residence Services

CPT Codes 99341-99350
Starting January 1, 2023, the 2 E/M visit families called Domiciliary, Rest Home (Boarding Home), or Custodial
Care services and Home services are now 1 E/M code family, Home or Residence services. Use the codes in
this family to report E/M services you provide to a patient in:
● Their home or residence
● An assisted living facility
● Group home (not licensed as an intermediate care facility for people with intellectual disabilities)
● Custodial care facility
● Residential substance abuse treatment facility

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There are no changes to the care settings for the current families. They’re in the new merged family. This
change removes CPT codes 99324-99337. Therefore, multiple Place of Service (POS) codes can be billed with
the new merged family of CPT codes 99341-99350 for Home or Residence Services:
● Home (POS 12)
● Assisted Living Facility (POS 13)
● Group Home (POS 14)
● Custodial Care Facility (POS 33)
● Residential Substance Abuse Treatment Facility (POS 55)

Prolonged Home or Residence E/M Visits

You may report reasonable and medically necessary prolonged services with the appropriate E/M codes
when you provide a prolonged Home or Residence Service that’s beyond the usual E/M visit. When you
select a Home or Residence E/M visit level using time, report prolonged Home or Residence E/M visit time
using HCPCS add-on code G0318 (Prolonged home or residence E/M services). You must meet all of the
requirements for prolonged services. For more information see Prolonged Services.

Nursing Facility Services

CPT Codes 99304–99310, 99315-99316, & 99318
You can’t bill an initial Nursing Facility (NF) service and another E/M service (like an office or other outpatient
visit or ED visit) on the same date of service for the same patient. You can count the time you spend providing
services in another setting toward reporting prolonged NF services if you meet the requirements for reporting
prolonged NF services.

Starting January 1, 2023, you can’t use CPT code 99318 (Other NF Service) to report an annual NF
assessment visit. You must use the regular Medicare Part B NF Services code set for dates of service on and
after January 1, 2023.

Prolonged Services
You may report prolonged E/M services for certain E/M visit families when the total visit time you spend with a
patient exceeds a certain time threshold. Report prolonged E/M services using Medicare-specific coding. When
reporting prolonged visits, you would report the codes for the primary service and the prolonged services.

Prolonged Office or Outpatient E/M Visits

HCPCS Add-on Code G2212
When you select a visit level using time, you may report a prolonged office or outpatient E/M visit time using
HCPCS add-on code G2212 (Prolonged office/outpatient E/M services).table provides reporting examples.

Table 2 gives reporting examples for prolonged office or outpatient E/M visits.

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Table 2. Codes for Billing Prolonged Office or Outpatient E/M Visits

Codes Total Time Required for Reporting*
99205 60-74 minutes
99205 x 1 and G2212 x 1 89-103 minutes
99205 x 1 and G2212 x 2 104-118 minutes
99215 40-54 minutes
99215 x 1 and G2212 x 1 69-83 minutes
99215 x 1 and G2212 x 2 84-98 minutes

99215 x 1 and G2212 x 3 or more for

99 or more
each additional 15 minutes

* Total time is all of the reportable time, including prolonged time, you spend with the patient on the date of service of the visit.

You may also report prolonged cognitive impairment assessment and care management services
(primary service CPT code 99483) using G2212, the Medicare-specific code for prolonged office and
outpatient services.

HCPCS Code G2212: Prolonged Office or Other Outpatient E/M Services

The following criteria apply:
● Use for services beyond the maximum time of the primary service you select using total time on
the date of the primary service
● Use for each additional 15 minutes beyond the maximum time you provide, with or without direct
patient contact
● List separately in addition to CPT codes 99205, 99215, 99483 for office or other outpatient
E/M services
● Don’t report G2212 on the same date of service as codes 99358, 99359, 99415, or 99416
● Don’t report G2212 for less than 15 additional minutes

The AMA’s E/M Services Guidelines (Guidelines for Selecting Level of Service Based on Time) lists
qualifying activities.

You may count these activities when:

● You use time to select your visit level
● Your services are medically reasonable and necessary

You’ll find 3 new Medicare-specific HCPCS codes (1 per E/M family) for billing prolonged Other E/M
services, listed below in Table 3.

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Prolonged Other E/M Visits

HCPCS Codes G0316, G0317, & G0318
Starting January 1, 2023, report prolonged Other E/M services using HCPCS codes G0316, G0317, and
G0318. Other E/M services include:
● Inpatient visits
● Observation visits
● NF visits
● Home or residence visits
● Cognitive impairment assessment and care planning

For timed visits, you may report prolonged Other E/M services with the highest visit level when your total visit
time exceeds a certain threshold.
● Don’t report prolonged services with ED visits or critical care services
● Prolonged services give you payment for additional practitioner time that isn’t already accounted
for in your primary service
● You can count your time spent providing qualifying activities when you perform them, and the total
time spent is at least 15 minutes beyond the total time shown below.

Table 3 summarizes billing prolonged Other E/M Services.

Table 3. Billing Prolonged Other E/M Visits

Count physician/NPP time
Prolonged Time Threshold to
Primary E/M Service spent within this time
Code* Report Prolonged
period (surveyed timeframe)
Initial IP/Obs. Visit (99223) G0316 90 minutes Date of visit
Subsequent IP/Obs. Visit
G0316 65 minutes Date of visit
(99233)
IP/Obs. Same-Day
Admission/Discharge G0316 110 minutes Date of visit to 3 days after
(99236)
IP/Obs. Discharge Day
N/A N/A N/A
Management (99238-9)
Emergency Department
N/A N/A N/A
Visits
1 day before visit + date of visit + 3
Initial NF Visit (99306) G0317 95 minutes
days after
Subsequent NF Visit 1 day before visit + date of visit + 3
G0317 85 minutes
(99310) days after
NF Discharge Day
N/A N/A N/A
Management

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Count physician/NPP time

Prolonged Time Threshold to
Primary E/M Service spent within this time period
Code* Report Prolonged
(surveyed timeframe)
Home/Residence Visit 3 days before visit + date of visit +
G0318 140 minutes
New Pt (99345) 7 days after
Home/Residence Visit 3 days before visit + date of visit +
G0318 110 minutes
Estab. Pt (99350) 7 days after
Cognitive Assessment
3 days before visit + date of visit +
and Care Planning G2212 100 minutes
7 days after
(99483)
Consults N/A N/A N/A
* You must use time to select your visit level.
NPP= non-physician practitioner
IP/Obs. = inpatient/observation

Prolonged NF Services
HCPCS Code G0317
Starting January 1, 2023, report prolonged NF services using Medicare-specific coding (HCPCS code G0317).
You can report prolonged services when you use time to select your visit level, and you exceed the total time
for the highest-level visit by 15 or more minutes providing reasonable and medically necessary services. You
can’t bill prolonged services with codes for NF discharge-day management.

Split (or Shared) E/M Services

CPT Codes 99202-99205, 99212-99215, 99221-99223, 99231-99239, 99281-99285, & 99291-99292
A split (or shared) service is an E/M visit where both a physician and NPP in the same group each personally
perform part of a visit that each 1 could otherwise bill if provided by only 1 of them. We pay the provider who
performs the substantive part of the visit.

Rules for reporting split (or shared) E/M services between a physician and NPP:
Hospital Inpatient, Outpatient, & ED Setting (99221-99223, 99231-99239, 99281-99285)
● In 2022-2023, the physician or NPP who provides more than 50% of the total time spent with the
patient or 1 of the 3 key parts (history, exam, or MDM) should bill for the visit
● In 2023, when you use 1 of the 3 key parts as the substantive portion, the physician or NPP who
bills the services must perform the key part in its entirety to bill the services
● You can’t bill services in these settings as split (or shared) services if Medicare regulations require
you to perform the entire visit (like certain Skilled Nursing Facility (SNF) visits

Critical Care Services

● Starting in 2022, the physician or NPP who provides more than 50% of the total time spent with
the patient should bill for the visit.

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● Unlike other E/M services, critical care services can include additional activities that are bundled
into the critical care visit codes 99291 and 99292. There’s a unique list of qualifying activities for
split (or shared) critical care. See the CPT Codebook for preferred descriptions.
● The same documentation rules apply for split (or shared) critical care visits as for other types of
split (or shared) E/M visits

SNF E/M Visits

● You may bill SNF E/M visits as split (or shared) visits if they meet the rules for split (or shared)
visit billing, except for SNF E/M visits that a physician must perform in their entirety
● NF visits don’t meet the definition of split (or shared) services

Billing & Documentation

● Use modifier FS (Split or Shared E/M Visit) on claims to report these services. This tells us that
even though you’re submitting the claim under 1 provider’s NPI, more than 1 provider performed
the visit.
● To bill split (or shared) critical care services, report CPT code 99291. If you spend 104 or more
cumulative total minutes providing critical care, report 1 or more units of CPT code 99292. Add
modifier FS to the critical care CPT codes on the claim.
● No matter where the split (or shared) visit took place, document the medical record to include:
○ The identity of both providers who perform the visit
○ Who performed the substantive portion of the visit

Submit the claim using the NPI for the provider who performed the substantive portion of the visit. That
provider must also sign and date the medical record.

Table 4 shows the definition of the substantive portion for E/M visit code families.

Table 4. Definition of Substantive Portion for E/M Visit Code Families

E/M Visit Code Family 2022-2023 Definition of Substantive Portion
Other Outpatient* History, or exam, or MDM, or more than 50% of total time
Inpatient, Observation, Hospital, and SNF* History, or exam, or MDM, or more than 50% of total time
Emergency Department History, or exam, or MDM, or more than 50% of total time
Critical Care More than 50% of total time
* You can’t bill office visits as split (or shared) services.

Distinct Time
You can only count distinct time for split (or shared) E/M services. When providers jointly meet with or discuss
the patient, you can only count the time of 1 provider.

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Qualifying Time
You can count the following list of activities toward total time to decide the substantive portion (except for
critical care visits), regardless of whether the activities involve direct patient contact:
● Preparing to see the patient (like review of tests)
● Getting or reviewing separately obtained history
● Performing a medically appropriate exam or evaluation
● Counseling and educating the patient/family/caregiver
● Ordering medications, tests, or procedures
● Referring and communicating with other health care professionals (when not separately reported)
● Documenting clinical information in the electronic or other health record
● Independently interpreting results (not separately reported) and communicating results to the
patient, family, or caregiver
● Coordinating care (not separately reported)

You can’t count time spent on these activities:

● Travel
● The performance of other services that you reported separately
● Teaching that’s general and isn’t limited to discussion of the management of a specific patient

For all split (or shared) visits, 1 of the providers must have face-to-face (in-person) contact with the patient, but
it doesn’t necessarily have to be the provider who performs the substantive portion and bills for the visit. The
substantive portion can be entirely with or without direct patient contact, and is determined by the proportion of
total time, not whether the time involves patient contact.

You can report split (or shared) visits for:

● New and established patients
● Initial and subsequent visits
● Prolonged services

In 2022-2023, when you use a key part as the substantive portion, use different approaches for hospital
outpatient E/M visits than other kinds of E/M visits:
● For shared hospital outpatient visits where you use a key part as the substantive portion, the
provider who reports the primary services may report prolonged services if the combined time of
both providers meets the threshold for reporting prolonged hospital outpatient services
● For all other kinds of E/M visits (except ED and critical care visits), the provider who reports the
primary service may report prolonged services when the combined time of both providers meets
the threshold for reporting prolonged E/M services other than office or outpatient E/M services

Both providers will add their time, and the provider with more than 50% of the total time (the substantive
portion), including prolonged time, will report both the primary service code and the prolonged services add-on
code, if they meet the time threshold for prolonged services.

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Table 5 summarizes reporting prolonged services for split (or shared) visits.

Table 5. Reporting Prolonged Services for Split (or Shared) Visits

2022-2023 2024
E/M Visit Code
Family If Substantive Portion If Substantive Portion Substantive Portion Must
is a Key Component is Time Be Time
Other Outpatient*
Combined time of both Combined time of both Combined time of both
Inpatient
practitioners must meet practitioners must meet practitioners must meet
Observation
the threshold for reporting the threshold for reporting the threshold for reporting
Hospital
prolonged services prolonged services prolonged services
SNF*
ED
N/A N/A N/A
Critical Care
* You can’t bill office visits as split (or shared) services.

General Principles of E/M Documentation

Clear and concise medical record documentation is critical to giving patients quality care and getting correct
and prompt payment for services. Medical records chronologically report a patient’s care and records related
facts, findings, and observations about the patient’s health history.

Medical record documentation helps you evaluate and plan the patient’s immediate treatment and watch their
health care over time.

Your MAC may ask for documentation to make sure a service is consistent with the patient’s insurance
coverage and to confirm:
● The site of service
● The medical necessity and appropriateness of the diagnostic or therapeutic services
● That you report services correctly

General principles of medical record documentation apply to all medical and surgical services and settings.
While E/M services vary, like the nature and amount of physician work needed, these general principles help
make sure medical record documentation is correct for all E/M services:
● The medical record should be complete and legible
● Your documentation of each patient encounter should include:
○ Reason for the encounter and relevant history, physical examination findings, and prior diagnostic
test results
○ Assessment, clinical impression, or diagnosis
○ Medical plan of care

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● If you don’t document the date, legible name of the observer and your rationale for ordering diagnostic
and other services, it should be easily inferred
● Past and present diagnoses should be accessible to you or the consulting physician
● You should identify appropriate health risk factors
● You should document the patient’s progress, response to and changes in treatment, and revision of
diagnosis
● Documentation in the medical record should report the diagnosis and treatment codes you report on the
health insurance claim form or billing statement

Document services during the encounter or as soon as possible after the encounter to keep the medical
record accurate.

Common Sets of Codes Used to Bill for E/M Services

When billing for a patient’s visit, choose codes that best characterize the services you give during the visit. A
billing specialist or alternate source may review your documentation before you send the claim. Reviewer may
help you choose codes that show the services you give to the patient. You must make sure:
● Your claim correctly shows your services
● The medical record documentation supports the level of service you report to a payer
● Don’t use the volume of documentation to decide the specific level of service to bill

Your services must meet the medical necessity guidelines in the statute, regulations, manuals, and the medical
necessity criteria in the National Coverage Determinations (NCDs) and Local Coverage Determinations(LCDs),
if any exist for the service reported on the claim. For every service billed, you must show the specific sign,
symptom, or patient complaint that makes the service reasonable and necessary.

HCPCS
HCPCS is the code set you use to report procedures, services, drugs, and devices you provide in the office,
hospital outpatient facility, ambulatory surgical center, or other outpatient facility. This system includes CPT
codes the AMA develops and supports.

Use HCPCS codes to report ambulatory services and physician services, including those physician services
you provide during an inpatient hospitalization.

ICD-10-CM
ICD-10-CM is a code set you use to report medical diagnoses on all claims for services you provide in the U.S.

ICD-10-PCS
ICD-10-PCS is a code set facilities use to report inpatient procedures and services they give patients in U.S.
hospital inpatient health care settings.

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E/M Services Providers

To get payment from Medicare for E/M services, your state must allow you to bill for E/M services within your
scope of practice.

Choosing the Code That Characterizes Your Services

To bill Medicare for an E/M services, you must choose a CPT code that best represents the:
● Patient type
● Setting of service
● Level of E/M service you provide the patient

Patient Type
For purposes of billing office and outpatient E/M services, we identify patients as either new or established,
depending on previous encounters with the provider. When billing certain other visit types (e.g., inpatient, NF),
the patient type is initial or subsequent.

New Patient: A person who didn’t receive any professional services from the physician. NPP, or another
physician of the same specialty who belongs to the same group practice within the previous 3 years.

Established Patient: A person who receives professional services from the physician, NPP, or another
physician of the same specialty who belongs to the same group practice within the previous 3 years.

Setting of Service
CMS categorizes E/M services into different settings depending on where you furnish the service. Examples of
settings include:
● Office or other outpatient setting
● Hospital inpatient
● ED
● NF

Level of E/M Service You Provide the Patient

The code sets to bill for E/M services are organized into categories and levels. In general, the more complex
the visit, the higher the level of code you may bill within the appropriate category.

To bill any code, the:

● Services you provide must meet the definition of the code
● Codes must reflect the services you provide

Medical necessity is the primary reason we pay for a service. It wouldn’t be medically necessary or appropriate
to bill a higher level of E/M service when a lower level of service is more appropriate.

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● As of January 1, 2023, for most E/M visit families, choose visit level based on the level of MDM or
the amount of time you spend with the patient
● For some types of visits (like ED visits and critical care), use only MDM or only time to bill

The CPT E/M Guidelines for MDM apply. For all E/M visits, your history and physical exam must meet the
descriptions in the code descriptors, but they don’t affect visit level selection. When you use time to select the
visit level, you must provide services for the full time.
● The general CPT rule about the midpoint for certain timed services doesn’t apply
● If you use time to support billing the E/M visit, document the medical record with the time spent
with patient using a start and stop time or the total time

Chief Complaint
A CC is a short statement that describes the symptom, problem, condition, diagnosis, or reason for the patient
encounter. The CC is usually stated in the patient’s own words, like patient complains of upset stomach, aching
joints, and fatigue. The medical record should clearly show the CC.

For more information, review the CY 2023 Physician Fee Schedule Final Rule (CMS-1770-F), and the CPT®
Evaluation and Management webpage.

History and Examination

When you perform E/M codes that have levels of services they include a medically appropriate history or
physical examination. The treating physician or other qualified health care professional reporting the service
determine the nature and extent of the history or physical examination. The care team may collect information,
and the patient or caregiver may supply information directly (by electronic health record [EHR] portal or
questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent
of history and physical examination is not an element in selection of the level of these E/M service codes.

Medical Decision Making

MDM is included in the CPT codes and services you submit on your claims. When selecting a level of MDM
for these services, review the 2023 Evaluation and Management (E/M) Services Guidelines for a detailed
breakdown the elements of MDM.

Other Considerations
Chronic Pain Management
HCPCS Codes G3002-G3003
Chronic pain is persistent or recurrent pain lasting longer than 3 months. When billing monthly chronic pain
management (CPM) services in 2023, use the 2 HCPCS codes below.

HCPCS G3002: Chronic Pain Management Services

Code G3002 describes a monthly bundle for chronic pain management and treatment services, including:
● Diagnosis, assessment, and monitoring
● Administering a validated pain rating scale or tool

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● Developing, implementing, revising, and maintaining a person-centered care plan that includes
strengths, goals, clinical needs, and desired outcomes
● Overall treatment management
● Facilitating and coordinating any necessary behavioral health treatment
● Medication management
● Pain and health literacy counseling
● Any necessary chronic pain related crisis care
● Ongoing communication and coordinating care between providers furnishing care (like physical
therapy and occupational therapy, complementary and integrative approaches, and community-
based care), as appropriate

These criteria apply:

● Requires an initial face-to-face visit of at least 30 minutes provided by a physician or other
qualified health professional
● First 30 minutes personally provided by physician or other qualified health care professional per
calendar month
● You must meet or exceed 30 minutes
● You must develop and maintain a person-centered plan
● Billable per calendar month
● You must provide the appropriate elements of the code bundle specific to each patient
● You don’t have to provide all of the bundled elements listed above every month

HCPCS G3003: Add-on Code for Chronic Pain Management Services

● Use code G3003 to bill for each additional 15 minutes of chronic pain management and treatment
by a physician or other qualified health care professional per calendar month
● List separately in addition to code G3002
● You must meet or exceed 15 minutes per calendar month

Consultation Services
CPT Codes 99251–99255 & 99241–99245
Medicare doesn’t recognize these codes for Part B payment purposes:
● Inpatient consultation codes (CPT codes 99251–99255)
● Office and other outpatient consultation codes (CPT codes 99241–99245)

Medicare recognizes telehealth consultation codes (HCPCS G0406–G0408 and G0425–G0427) for payment.

If you provide services using CPT consultation codes, you should report the correct E/M visit code to bill for
these services.

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Teaching Physician Services

The AMA CPT office or outpatient E/M visit coding framework allows you to choose the office or outpatient E/M
visit level to bill, based on the total time you personally spent with the patient or MDM (with or without direct
patient contact on the date of the service), including the time you’re present when the resident is performing
qualifying activities.

Starting January 1, 2022, you may include the time a teaching physician is present with the patient when
determining E/M visit level. Under the primary care exception, you can only use MDM to choose the visit level.
This limits the possibility of inappropriate coding based on residents’ inefficiencies instead of a measure of the
time for the services. See CR 12543.

Telehealth Services
HCPCS Codes G0316-G0318, G3002-G3003
Starting January 1 2023, we’re adding these new HCPCS codes to the list of Medicare telehealth services on a
Category 1 basis: HCPCS codes G0316, G0317, G0318, G3002, and G3003.

We pay for specific Medicare Part B services that a physician or practitioner provides via 2-way, interactive
technology (or telehealth). Telehealth substitutes for an in-person visit, and generally involves 2-way,
interactive technology that permits communication between the practitioner and patient.

During the COVID-19 public health emergency (PHE), we used emergency waiver and other regulatory
authorities so you could provide more services to your patients via telehealth. Section 4113 of the Consolidated
Appropriations Act, 2023 extended many of these flexibilities through December 31, 2024, and made some of
them permanent.

For dates of service in 2023, continue billing telehealth services with the POS you would bill for an in-person
visit. You must use modifier 95 to show they’re telehealth services until December 31, 2023. See list of codes
added to the telehealth services list.

The COVID-19 public health emergency (PHE) ended at the end of the day on May 11, 2023. View
Infectious diseases for a list of waivers and flexibilities that were in place during the PHE.

See the MLN® Telehealth Services fact sheet for information on:
● Originating and distant sites
● Telehealth requirements
○ Section 4113 of the Consolidated Appropriations Act, 2023
● Currently covered telehealth
○ List of Telehealth Services ZIP file
○ Provider Billing Medicare FFS Telehealth
● Billing & payment

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● New HCPCS G codes for home health telehealth

○ See MLN Matters Article MM12805
● Consent for care management & virtual communication services

Visit the HHS Telehealth Policy webpage or review the AMA’s Telehealth Quick Guide. It’s intended to help
physicians, practices and health systems navigate changes to flexibilities. It includes information on:
● Practice Implementation
● Policy, Coding & Payment

Resources
● 2023 CPT E/M descriptors and guidelines (ama.org)
● 2024 ICD-10-CM
● 2024 ICD-10-PCS
● Calendar Year (CY) 2023 Medicare Physician Fee Schedule Final Rule Fact Sheet
● CPT® Books
● CPT® Evaluation and Management
● Evaluation and Management (E/M) Visits
● Evaluation and Management (E/M) Visit FAQs Physician Fee Schedule (PFS)
● HCPCS
● HHS Telehealth Policy
● Medicare Benefit Policy Manual
● Medicare Claims Processing Manual
● Medicare Information for Patients
● Medicare Learning Network® (MLN) Products
● MLN Matters® Article MM 12982 - Medicare Physician Fee Schedule Final Rule Summary: (CY) 2023
● Reporting CPT Modifier 25
● Telehealth Quick Guide (ama.org)
● Telehealth Policy Changes after the COVID-19 PHE
● Tuesday, November 8, 2022-Transcript, Q&A and Audio File-Physicians Open Door Forum (ZIP) file

Medicare Learning Network® Content Disclaimer, and Department of Health & Human Services Disclosure

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S.
Department of Health & Human Services (HHS).

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