Evaluation and Management (E/M) codes with add-ons

Updated

An evaluation and management (E/M) service is when a physician or other qualified health professional diagnoses and treats an illness or injury.

 

Using E/M codes

Headway has new patient and existing patient E/M service codes available. Below you can find the evaluation and management services available.

New patient codes Existing patient codes
99202, 99203, 99204, 99205

Evaluation and Management codes can be based on either time or Medical Decision Making (MDM) when coded without an add-on psychotherapy service.  

When an E/M service is combined with an add on psychotherapy code such as 90833, 90836, or 90838, the Evaluation & Management Service must be based on MDM, while the psychotherapy add on code is based on minutes of psychotherapy provided directly to the client. Both services must be documented as distinct services in session documentation. 

When documenting use of a psychotherapy add-on code, ensure that you use the exact time in minutes, rather than a range. For example: “provided 45 minutes of supportive psychotherapy.” 

As a reminder, the associated times for psychotherapy add-on codes are: 

  • 90833: 16-37 minutes
  • 90836: 38-52 minutes
  • 90838: 53+ minutes
 

New vs. existing patients

New patient: An individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice and the same specialty within the previous 3 years.

Existing patient: An individual who has received professional services from the physician or another physician in the same group and the same specialty within the previous 3 years.

 

Selecting Evaluation and Management services based on time

Documentation of work on the date of service is imperative when billing based on time. Be sure to justify why you spent a certain amount of time with the client within your documentation. 

New patient code Time
99202 15-29 minutes
99203 30-44 minutes
99204 45-59 minutes
99205 60-74 minutes
Established patient code Time
99212 10-19 minutes
99213 20-29 minutes
99214 30-39 minutes
99215 40-54 minutes


The following activities count toward
time when coding an E/M service: 

  • Preparing to see the patient on the date of service (e.g., review of tests)
  • Obtaining and/or reviewing the separately obtained history on the date of service
  • Performing a medically appropriate examination and/or evaluation on the date of service
  • Ordering medications, tests, and procedures on the date of service
  • Counseling and educating the patient/family/caregiver on the date of service
  • Referring and communicating with other health care professionals (when not reported separately) on the date of service
  • Documenting clinical information in the electronic or other health records
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • Care coordination (not separately reported)

 

The following activities do not count toward time when coding an E/M Service: 

  • Time spent on a previous or subsequent day
  • Activities performed by clinical staff (i.e., RNs, MAs)
  • When the E/M is warranted and separately identifiable, the time spent on separately reportable services (such as procedures, diagnostic tests, and professional interpretation) cannot be combined with the E&M time
  • Time spent on travel
  • Time spent on teaching that is general

 

Selecting Evaluation and Management services based on Medical Decision Making

Medical Decision Making level is determined by the qualifications in the table below. The session must meet the requirements of 2 out of the 3 elements of Medical Decision Making.

EMCodeTable_forCapturinginZendeskContent_.png

** For definitions of the terms in the table above, see the glossary

Click on each Level of Medical Decision Making (Based on 2 out of 3 elements of MDM) below to see a breakdown. 

Straightforward (99212 or 99202)

Number and complexity of problems addressed

Amount and/or complexity of data to be reviewed and analyzed

  • Minimal or none

Risk of complications and/or morbidity or mortality of patient management

  • Minimal risk of morbidity from additional diagnostic testing or treatment
Low (99213 or 99203)

Number and complexity of problems addressed

Amount and/or complexity of data to be reviewed and analyzed

  • Either Category 1 or Category 2 conditions are met 
    • Category 1: Tests and documents
      • Any combination of 2 from the following 
        • Review of prior external note(s) from each unique source 
        • Review of the result(s) of each unique test 
        • Ordering of each unique test 
    • Category 2: Assessment requiring an independent historian(s) 
      • For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high

Risk of complications and/or morbidity or mortality of patient management

  • Low risk of morbidity from additional diagnostic testing or treatment
Moderate (99214 or 99204)

Number and complexity of problems addressed

Amount and/or complexity of data to be reviewed and analyzed

  • At least 1 of the categories below must be met 
    • Category 1: Tests, documents, or independent historian(s) 
      • Any combination of 3 from the following: 
        • Review of prior external note(s) from each unique source 
        • Review of the result(s) of each unique test 
        • Ordering of each unique test 
        • Assessment requiring an independent historian(s)
    • Category 2: Independent interpretation of tests 
      • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported) 
    • Category 3: Discussion of management or test interpretation
      • Discussion of management or test interpretation with external physician / other qualified health care professional / appropriate source (not separately reported) 

Risk of complications and/or morbidity or mortality of patient management

  • Moderate risk of morbidity from additional diagnostic testing or treatment
  • Examples only: 
    • Prescription drug management 
    • Decision regarding minor surgery with identified patient or procedure risk factors
    • Decision regarding elective major surgery without identified patient or procedure risk factors
    • Diagnosis or treatment significantly limited by social determinants of health  
High (99215 or 99205)

Number and complexity of problems addressed

Amount and/or complexity of data to be reviewed and analyzed

  • At least 2 of the categories below must be met 
    • Category 1: Tests, documents, or independent historian(s) 
      • Any combination of 3 from the following: 
        • Review of prior external note(s) from each unique source* 
        • Review of the result(s) of each unique test*
        • Ordering of each unique test*
        • Assessment requiring an independent historian(s)
    • Category 2: Independent interpretation of tests 
      • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported) 
    • Category 3: Discussion of management or test interpretation
      • Discussion of management or test interpretation with external physician / other qualified health care professional / appropriate source (not separately reported)

Risk of complications and/or morbidity or mortality of patient management

  • High risk of morbidity from additional diagnostic testing or treatment
  • Examples only: 
    • Drug therapy requiring intensive monitoring for toxicity
    • Decision regarding elective major surgery with identified patient or procedure risk factors
    • Decision regarding emergency major surgery
    • Decision regarding hospitalization or escalation of hospital level care
    • Decision not to resuscitate or to de-escalate care because of poor prognosis
    • Parenteral controlled substances

 

Examples of E/M codes

Providers use CPT (Current Procedural Terminology) codes when confirming sessions in our system. These codes correspond with things like the type of care provided (i.e., psychotherapy) and the length of time for the session.

Read more about CPT codes on Headway

E/M (Evaluation and Management) codes are a specific range of CPT codes used primarily by a certain kind of provider—typically physicians, psychiatrists and nurse practitioners—who evaluate and manage a client’s health.

A few common examples of E/M codes include:

  • Codes for an office or other outpatient visit for new clients with the following session lengths
    • 99202 (Straightforward): 15-29 minutes
    • 99203 (Low MDM): 30-44 minutes
    • 99204 (Moderate MDM): 45-59 minutes
    • 99205 (High MDM): 60-74 minutes 
  • Codes for an office or other outpatient visit for established clients with the following session lengths:
    • 99212 (Straightforward): 10-19 minutes
    • 99213 (Low MDM): 20-29 minutes
    • 99214 (Moderate MDM): 30-39 minutes
    • 99215 (High MDM): 40-54 minutes

 

There are two approaches to keep in mind when billing Evaluation and Management (E/M) Services in the outpatient setting:

  1. If coding for an E/M code alone, such as those listed above, you may select your code based on the length of the session or Medical Decision Making.
  2. If coding an E/M code along with psychotherapy, you must use Medical Decision Making (MDM) to justify your use of the E/M code.

 

Medical Decision Making (MDM)

MDM is a type of decision making that helps establish diagnosis, assess the status of a condition, and determine the right kind of management. It’s typically broken into three elements:

  1. The number and complexity of problem(s) that are addressed during the session.
  2. The amount or complexity of data you need to review and analyze. This data includes medical records, tests, and/or other information that must be obtained, ordered and reviewed. This also might include information obtained from multiple sources or other team members.
  3. The risk of complications, morbidity or mortality arising from management decisions made at the visit—associated with the client’s problem(s), the diagnostic procedure(s), and treatment(s).
Note that comorbidities are not considered unless they are addressed during the session or add complexity or risk to the management of the client.

Please visit this AMA guide for the latest criteria for MDM, starting with the chart on page 8: Evaluation and Management Service Guidelines.

 

Add-on codes

E/M services can sometimes require add-on codes if you provide further care or psychotherapy in addition to medical and evaluation. For example, the following codes can be added:

  • 90833: Individual psychotherapy, 30 minutes
    • 16-37 minutes face to face with the client
  • 90836: Individual psychotherapy, 45 minutes
    • 38-52 minutes face to face with the client
  • 90838 - Individual psychotherapy, 60 minutes
    • 53 minutes or more face to face with the client

Please note that these codes can only be used with an E/M code (99202-99215).

For psychotherapy add-on codes, documentation must:

  • Be clearly separate from the evaluation and management (E/M) section

    • For example, it should be in its own distinct section or paragraph that is easily identifiable apart from the E/M documentation

  • Include all of the following:  
    • Clearly identified issues addressed during the psychotherapy session
    • The precise duration of time spent conducting psychotherapy (number of minutes OR start/stop time)
    • Description of interventions or modalities utilized (e.g., CBT, DBT, motivational interviewing) to address the issues identified
    • A treatment plan outlining goals for the psychotherapy
    • Assessment of the client's progress toward the established treatment plan and goals, indicated as Progressing, Regressing, or Maintaining
    • Mention of client’s need for follow-up care and the cadence

Alternatively, you can use the BIRP Method for your add-on psychotherapy documentationPlease note: Your notes don't need to be as detailed as the example provided; typically, 1-2 complete sentences for each section is sufficient.

 

Glossary of terms and definitions

 

Term Definition

Self-limited minor problem 

A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status

Example: Bereavement 

Stable, chronic illness

A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). "Stable" for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. 

Example: Major Depressive Disorder, recurrent, in remission

Stable, acute illness

A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.

Example: Acute stress reaction

Acute, uncomplicated illness

A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.

Example: Adjustment disorder with depressed mood

Acute, complicated illness

An illness that causes systemic symptoms and has a high risk of morbidity without treatment.

Example: Anorexia with bradycardia or amenorrhea

Chronic illnesses with exacerbation, progression or side effects from treatment

A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects.

Example: Major Depressive Disorder, recurrent; moderate

Undiagnosed new problem with uncertain prognosis

A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.

Example: Cognitive Decline

Chronic illness with severe exacerbation, progression, or side-effects of treatment

The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.

Example: Major Depressive Disorder, recurrent, severe w/ significant functional decline

Acute or chronic illness or injury that poses a threat to life or bodily function

An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity.

Example: Depression with suicidal ideation and plan

Social Determinants of Health

Economic and social conditions that influence the health of people and communities.

Examples of social determinants of health that contribute to medication non-adherence include food or housing insecurity.

Drug Therapy requiring intensive monitoring for toxicity

A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy.
Examples: Initiation of Lithium, management of Clozapine

 

Disclaimer

This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.

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