E/M Services

For many practices, E/M services are what you do the most. Knowing what type of service to bill, what level of service and the rules related to the visit will decrease denials and payment delays. Here you'll find an overview, MDM and rule changes, resources organized just like your CPT book, and a bonus section with E/M frequency data.

Anatomy of an Audit™: Complexity of Problem Addressed | Webinar

Event Date May 22nd, 2025

Guest presenters Pam D’Apuzzo, CPC, ACS-EM, ACS-MS, CPMA and Debra Rossi, CCS, CCS-P, CPC, CPMA of VMG Health

Combining CPT® guidance and extensive audit experience, this session will address definitions and documentation related to acute and chronic conditions, stable or with exacerbation/progression or side-effect, how an undiagnosed new problem with an uncertain outcome differs from an acute, uncomplicated condition, and have examples of an illness with systemic symptoms and “high” in the number and complexity of problems addressed.

Coding and Auditing Critical Care Notes | Webinar

Event date May 8th, 2025

This webinar will review CPT guidance for reporting critical care, including the condition of the patient, the interventions, and time spent. The webinar will discuss what services may be reported separately from critical care.

The Ins and Outs of Assessing RISK within the MDM Component | Webinar

Recorded April 24, 2025

Guest presenter Seth Canterbury, CPC, CPC-I

When the method for selecting the level of E/M services was changed for 2021 (office visits) and 2023 (other visits), the concept of “risk” underwent significant revision. No longer was this concept confined to just one element/subcomponent of MDM.

Transferring a Sick Baby to Another Hospital

Question: Our pediatric group practices in a community hospital, without an NICU. My pediatrician was called to attend a delivery of a newborn who was born premature and in respiratory distress. The baby needed to be stabilized and transferred to a level III neonatal intensive-care unit. The pediatrician spent 90 minutes from the time the […]

E/M Frequency Data for Dermatology

For dermatologists, revenue in the office is generated by procedures and office visits. Often, both are provided on the same day. See the dermatology section of our specialty page for articles about the use of modifiers 25, 51, and 59. Frequency distribution for new and established patients 2023 E/M data released at the end of […]

Coding for Prolonged Services | Webinar

Recorded April 17, 2025

Coding for prolonged services requires practitioner education, careful documentation and coder oversight. These codes are the opposite of “set and forget.” CPT and CMS use different codes and have different time thresholds. For some services, CMS allows time spent on services done on a different date!

Coding Guide – Prolonged Services

Prolonged services codes function as add-on codes to the highest-level Evaluation and Management (E/M) services in certain categories. To use prolonged care, providers must select the primary code based on time, which is explicitly stated in both the CPT® and HCPCS definitions of prolonged services. For billing purposes, the full 15 minutes of prolonged services […]

Anatomy of an Audit™

Recorded February 4th, 2025

Evaluation & Management E/M Services: Guest presenters Pam D’Apuzzo, CPC, ACS-EM, ACS-MS, CPMA and Debra Rossi, CCS, CCS-P, CPC, CPMA of VMG Health

Surgical Procedures & Diagnostic Tests: Guest presenter Pam Warren, MHA, COC, CPC, Fellow

Auditing an individual record is one part of conducting an internal or external audit. Anatomy of an audit will look at the entire audit process including: identifying the type and purpose of the audit, necessary research, record selection, utilization of appropriate audit tools, and reporting and response.

FAQ: Scoring Elements in the E/M Guidelines

Scoring MDM elements can be challenging for E/M services This post includes questions related to: Major/Minor procedure Data Elements (with link to additional resources) General questions about the guidelines Using time (with link to additional resources) Social determinants of health Major or minor procedure? Question: I have a question about how to determine if a […]

The First Element of MDM: Number and Complexity of Problems Addressed

E/M elements for MDM There are three elements in medical decision-making and this article describes the first of three When selecting a level of service based on medical decision-making two of the three elements are required CPT® has developed definitions for many of the components in the MDM chart. The examples listed in the definitions […]

The Second Element of MDM: Amount and/or Complexity of Data

There are three elements in medical decision-making and this article describes the second, arguably, the most complex of the three elements When selecting a level of service based on medical decision-making two of the three elements are required CPT® has developed definitions for many of the components in the MDM chart. This article describes the definitions […]

The Third Element of MDM: Risk of Complications

The third element of MDM: risk of complications and/or morbidity or mortality of patient management at the encounter Coding for E/M services There are three elements in medical decision-making and this article describes the third, the risk of complications and/or morbidity or mortality related to patient management When selecting a level of service based on […]

Consultation Codes

First, CMS stopped recognizing consult codes in 2010. Outpatient consultations (99241—99245) and inpatient consultations (99251—99255) were still active CPT® codes, and depending on where you are in the country, are recognized by a payer two, or many payers. In 2023, codes 99241 and 99251 are deleted. These two low level consult codes were rarely used. […]

Coding for Observation Services

CPT codes for observation services Beginning January 1, 2023 there are two sets of codes used for both inpatient status and observation level of care. Coding for observation services no longer has a distinct set of CPT® codes, those were deleted. Use 99221–99223 for initial inpatient or observation care services and use 99231–99233 for inpatient […]

Codes for Visits in Assisted Living

Question: In 2023, how will we code for visits in assisted living? Answer: January 1st 2023, the codes for boarding home, rest home and domiciliary care are gone from the CPT® book. What are the codes for visits in assisted living in 2023 and beyond? Home and residence services (99341—99345 for new patients) and (99347—99350 […]

Acute, Uncomplicated vs. Acute with Systemic Symptoms

Question: When using the E/M guidelines, is the problem an an acute, uncomplicated illness or an acute illness with systemic symptoms? Answer: Let’s start with the CPT definitions, from the CPT® Professional edition. Acute, uncomplicated illness Acute illness with systemic symptoms From CPT®: A recent or new short-term problem with low risk of morbidity for […]

Critical Care Services

Definition and Explanation of Critical Care Service Definition: Coding service for caring for a critically ill or injured patient Explanation: Critical care has high relative value units and payments so it’s important to know the coding rules. This article describes what can be included in the time of critical care what can’t be included, and […]

Risk: Roads not Taken

How is risk evaluated when selecting a level of E/M service? We know that the risk from additional diagnostic testing/procedures and management is one of the three elements that determines the level of service, when MDM is used. But, how about the risk from the condition itself? This short video (I always say they’re short […]

Coding for Prolonged Services: CPT and HCPCS Codes

Common rules: Prolonged services codes are add-on codes to the highest level E/M services in certain categories. In order to use prolonged care, the primary code must be selected based on time. This is in the CPT and HCPCS definition of prolonged services. Prolonged services codes may only be added to the highest-level code in […]

Nursing Facility Visits

Definition Nursing facility visits are Evaluation and Management services provided in a skilled nursing facility or a long term nursing facility. Explanation Only a physician may perform an initial nursing facility service in a SNF. This includes admissions and re-admissions. In an NF, a non-physician practitioner (NPP) who is not employed by the NF may […]

Home and Nursing Facility Category of Code Rules | Webinar

Recorded March 21st, 2024

This webinar will explain the rules for using Evaluation and Management (E/M) services (E/M) in home and residence locations and nursing and skilled nursing facilities. This includes CMS regulations for nursing facility services. It will discuss reporting multiple E/M services when one of the visits is in a nursing facility. It will describe the correct category of code for…

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