Evaluation and Management Codes – 99201-99499

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Evaluation and Management Codes - 99201-99499

Before we explore the Evaluation and Management Codes (E/M) services guidelines, let’s highlight a very important change from CMS, that although made in 2010 continues to cause confusion. The change pertains to “Consultation services.”

Effective from January 2010, Medicare no longer recognizes the consultation services (99241-99255) and requires the use of appropriate office or inpatient visit codes (99201-99215 & 99221 99233) in place of these services. Across chapters in this book, we have marked the consultation codes (99241-99255) with an asterisk (*). However, the consultation codes have not been removed from the CPT® manual and it is at the discretion of other payers to decide to accept these services.

A coder might still need the guidelines for consultation services if the payer agrees to pay for them. Hence, the general guidelines pertaining to consultations are still available. Moreover, we have added the changes in rules pertaining to those services to help the coding community understand the changes and the impact those changes have on reimbursement. The word “Consultation” may occur multiple times, and the reader is advised to follow the guidelines pertaining to them in the relevant chapter, i.e., Chapter 6: Consultations (99241 99255).

Evaluation and Management Codes From 99201 To 99499:

99201:

The provider spends approximately10 minutes face to face with a new patient and/or the patient’s family in the provider’s office or in another outpatient setting to evaluate and manage self-limited or minor medical problems. The provider’s evaluation consists of all three of these components: a problem-focused history, a problem focused physical examination, and straightforward medical decision making. She may provide additional services, including counseling or coordination of care with other healthcare professionals or agencies, if necessary.

99202:

The provider spends approximately 20 minutes face to face with a new patient and/or the patient’s family in the provider’s office or in another outpatient setting to evaluate and manage the patient’s medical problems, which are usually of low to moderate severity. The provider’s evaluation consists of all three of these components: an expanded problem-focused history, an expanded problem focused physical examination, and straightforward medical decision making. She may provide additional services, including counseling or coordination of care with other healthcare professionals or agencies, if necessary.

99203:

The provider spends approximately 30 minutes face to face with a new patient and/or the patient’s family in the provider’s office or in another outpatient setting to evaluate and manage the patient’s medical problems, which are usually of moderate severity. The provider’s evaluation consists of all three of these components: a detailed history, a detailed physical examination, and medical decision making of low complexity. She may provide additional services, including counseling or coordination of care with other healthcare professionals or agencies, if necessary.

99204:

The provider spends approximately 45 minutes face to face with a new patient and/or the patient’s family in the provider’s office or in another outpatient setting to evaluate and manage the patient’s medical problems, which are usually of moderate to high severity. The provider’s evaluation consists of all three of these components: a comprehensive history, a comprehensive physical examination, and medical decision making of moderate complexity. She may provide additional services, including counseling or coordination of care with other healthcare professionals or agencies, if necessary.

99205:

The provider spends approximately 60 minutes face to face with a new patient and/or the patient’s family in the provider’s office or in another outpatient setting to evaluate and manage the patient’s medical problems, which are usually of moderate to high severity. The provider’s evaluation consists of all three of these components: a comprehensive history, a comprehensive physical examination, and medical decision making of high complexity. She may provide additional services, including counseling or coordination of care with other healthcare professionals or agencies, if necessary.