2024

E&M Coding Tips

Guidebook
YOUR ESSENTIAL GUIDE FOR 2024

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 2024 E&M Coding Tips Guidebook Introduction
Evaluation and management (E&M) services are utilized for problem focused visits performed in all
healthcare settings. These are cognitive services in which a physician or other qualified healthcare
professional diagnose and treat illnesses or injuries.

Code selection in most E&M categories is based on either time or medical decision making. It is truly
important for providers, coders, auditors, educators and template developers to understand the
E&M guidelines to maintain compliance with coding and documentation.

Panacea’s experts compiled this guidebook as an easy reference for coding professionals. In it,
you’ll find tip sheets and reference articles for several different categories of E&M coding.

Included in the Guidebook:

2024 E&M Coding Tip Sheets
– Consultation Visits
– Emergency Department Visits
– Hospital Inpatient and Observation Care
– Office or Other Outpatient Services
– Critical Care

Critical Care Documentation and Examples Tip Sheet

Split Shared Services Reference Sheet
Medical Decision Making Guidelines
2024 Medical Decision Making Table

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 2024 Evaluation and Management Consultation Visits
Medical Decision Making (MDM)
Using Medical Decision Making (MDM) as the determining factor:

Code (level) selection requires two of the following three elements be met:
• Number and complexity of problem(s) addressed during the encounter
− Count only diagnoses receiving active treatment during the encounter
− See Medical Decision Making Table for examples for each level*
• Amount / Complexity of data to be reviewed and analyzed
− Changes reflect specific combinations of work to score MDM*
• Risk of complications, morbidity / mortality of patient management decisions made at the visit
− See Medical Decision Making Table for examples for each level*

Levels of MDM for Outpatient Consultations*

MDM Code Problems Addressed Data to Review Risk

Straightforward 99242 Straightforward Minimal / None Minimal
Low 99243 Low Limited Low
Moderate 99244 Moderate Moderate Moderate
High 99245 High Extensive High

Levels of MDM for Inpatient Consultations*

MDM Code Problems Addressed Data to Review Risk

Straightforward 99252 Straightforward Minimal / None Minimal
Low 99253 Low Limited Low
Moderate 99254 Moderate Moderate Moderate
High 99255 High Extensive High

*Refer to the Medical Decision Making Table (page 21) for detailed requirements for each level of MDM.

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 2024 Evaluation and Management Consultation Visits – Time
Using Time as the determining factor:

• Includes total time spent by the physician or other qualified healthcare professional (face-to-face
and non-face-to-face on the same date of service)

Activities Included in Total Time:

• Preparing to see the patient (e.g., review of tests)
• Obtaining and / or reviewing separately attained history
• Performing a medically appropriate examination and / 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 / caregiver
• Care coordination (not separately reported)

Activities NOT Included in Total Time:

• Time spent on separately reported services such as minor procedures, diagnostic studies, or any
service reported on the same date of service
• Activities performed by clinical staff such as vital signs, recording history, etc.

Time Ranges for Outpatient and Inpatient Consultation Visits

Outpatient Consultations Inpatient Consultations

Code Time Threshold Code Time Threshold
99242 20 min meet or exceed 99252 35 min meet or exceed
99243 30 min meet or exceed 99253 45 min meet or exceed
99244 40 min meet or exceed 99254 60 min meet or exceed
99245 55 min meet or exceed 99255 80 min meet or exceed

Prolonged Services Codes

• May only be used when time is the determining factor
• May only be used with Level 5 codes – 99245 and 99255
• Fifteen-minute increments

Next Page 
Time Ranges for Prolonged Service Codes

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 Time Ranges for Prolonged Service Codes*

Total Duration of Outpatient Consult Code(s) Reported

<70 minutes Report appropriate E&M code 99245
70 – 84 minutes 99245 x 1 and 99417 x 1
85 – 99 minutes 99245 x 1 and 99417 x 2
100 + minutes 99245 x 1 and 99417 x 3 + 1 for ea add’l 15 min

Total Duration of Inpatient Consult Code(s) Reported

<95 minutes Report appropriate E&M code 99255
95 – 109 minutes 99255 x 1 and 99418 x 1
110 – 124 minutes 99255 x 1 and 99418 x 2
125 + minutes 99255 x 1 and 99418 x 3 + 1 for ea add’l 15 min

*CMS guidelines differ from AMA guidelines. Use CMS guidelines when reporting to Medicare / Medicaid.

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 2024 Evaluation and Management Emergency Department Visits
Medical Decision Making (MDM)
Using Medical Decision Making (MDM) as the determining factor:

Code (level) selection requires two of the following three elements be met:

• Number and complexity of problem(s) addressed during the encounter

− Count only diagnoses receiving active treatment during the encounter

− See Medical Decision Making Table for examples for each level*

• Amount / Complexity of data to be reviewed and analyzed

− Changes reflect specific combinations of work to score MDM*

• Risk of complications, morbidity / mortality of patient management decisions made at the visit

− See Medical Decision Making Table for examples for each level*

Levels of MDM for Emergency Department Visits

MDM Code Problems Addressed Data to Review Risk

Straightforward 99282 Straightforward Minimal / None Minimal
Low 99283 Low Limited Low
Moderate 99284 Moderate Moderate Moderate
High 99285 High Extensive High

*Refer to the Medical Decision Making Table (handout) for detailed requirements for each level of MDM.

Time is not an element that may be used for code selection criteria with the
Emergency Department Evaluation and Management category of codes.

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 2024 Evaluation and Management Hospital Inpatient and Observation Care
Medical Decision Making (MDM)

Using Medical Decision Making (MDM) as the determining factor:

Code (level) selection requires two of the following three elements be met:

• Number and complexity of problem(s) addressed during the encounter

− Count only diagnoses receiving active treatment during the encounter
− See Medical Decision Making Table for examples for each level*
• Amount / Complexity of data to be reviewed and analyzed
− Changes reflect specific combinations of work to score MDM*
• Risk of complications, morbidity / mortality of patient management decisions made at the visit
− See Medical Decision Making Table for examples for each level*

Levels of MDM for Hospital Initial Hospital or Observation Care*

MDM Code Problems Addressed Data to Review Risk

Straightforward or Low 99221 Straightforward or Low None, Minimal or Limited Minimal or Low
Moderate 99222 Moderate Moderate Moderate
High 99223 High Extensive High

Levels of MDM for Hospital Subsequent Hospital or Observation Care*

MDM Code Problems Addressed Data to Review Risk

Straightforward or Low 99231 Straightforward or Low None, Minimal or Limited Minimal or Low
Moderate 99232 Moderate Moderate Moderate
High 99233 High Extensive High

Levels of MDM for Hospital Same Day Admit / Discharge Hospital or Observation Care*

MDM Code Problems Addressed Data to Review Risk

Straightforward or Low 99234 Straightforward or Low None, Minimal or Limited Minimal or Low
Moderate 99235 Moderate Moderate Moderate
High 99236 High Extensive High

*Refer to the Medical Decision Making Table (page 21) for detailed requirements for each level of MDM.

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 2024 Evaluation and Management Hospital Inpatient and Observation Care –
Time
Using Time as the determining factor:
• Includes total time spent by the physician or other qualified healthcare professional (face-to-face and
non-face-to-face on the same date of service)
Activities Included in Total Time:
• Preparing to see the patient (e.g., review of tests)
• Obtaining and / or reviewing separately attained history
• Performing a medically appropriate examination and / 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 / caregiver
• Care coordination (not separately reported)
Activities NOT Included in Total Time:
• Time spent on separately reported services such as minor procedures, diagnostic studies, or any
service reported on the same date of service
• Activities performed by clinical staff such as vital signs, recording history, etc.

Time Ranges for Initial and Subsequent and Same Day Admit / Discharge
Code Time Threshold Code Time Threshold Code Time Threshold
99221 40 min meet or exceed 99231 25 min meet or exceed 99234 45 min meet or exceed
99222 55 min meet or exceed 99232 35 min meet or exceed 99235 70 min meet or exceed
99223 75 min meet or exceed 99233 50 min meet or exceed 99236 85 min meet or exceed

Prolonged Services Codes

• May only be used when time is the determining factor
• May only be used with highest level code from the category – 99223, 99233 and 99236
• Fifteen minute increments
Time Ranges for Prolonged Service Codes*
Duration of Initial Hospital Visit Code(s) Reported
< 90 minutes Report appropriate E&M code 99223
90 – 104 minutes 99223 x 1 and 99418 x 1
105 + minutes 99223 x 1 and 99418 x 2 + 1 for ea add’l 15 min
Duration of Subsequent Hosp Visit Code(s) Reported
< 65 minutes Report appropriate E&M code 99233
65 – 79 minutes 99233 x 1 and 99418 x 1
80 + minutes 99233 x 1 and 99418 x 2 + 1 for ea add’l 15 min *CMS guidelines
Duration of Same Day Admit / DC Visit Code(s) Reported differ from AMA
guidelines. Use
< 100 minutes Report appropriate E&M code 99236 CMS guidelines
when reporting to
100 – 114 minutes 99236 x 1 and 99418 x 1 Medicare /
115 + minutes 99236 x 1 and 99418 x 2 + 1 for ea add’l 15 min Medicaid.

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 2024 Evaluation and Management Office or Other Outpatient Visits
Medical Decision Making (MDM)
Using Medical Decision Making (MDM) as the determining factor:

Code (level) selection requires two of the following three elements be met:

• Number and complexity of problem(s) addressed during the encounter

− Count only diagnoses receiving active treatment during the encounter
− See Medical Decision Making Table for examples for each level*
• Amount / Complexity of data to be reviewed and analyzed
− Changes reflect specific combinations of work to score MDM*
• Risk of complications, morbidity / mortality of patient management decisions made at the visit
− See Medical Decision Making Table for examples for each level*

Levels of MDM for Office or Other Outpatient Services – New Patient*

MDM Code Problems Addressed Data to Review Risk

Straightforward 99202 Straightforward Minimal / None Minimal
Low 99203 Low Limited Low
Moderate 99204 Moderate Moderate Moderate
High 99205 High Extensive High

Levels of MDM for Office or Other Outpatient Services – Established Patient*

MDM Code Problems Addressed Data to Review Risk

Straightforward 99212 Straightforward Minimal / None Minimal
Low 99213 Low Limited Low
Moderate 99214 Moderate Moderate Moderate
High 99215 High Extensive High

*Refer to the Medical Decision Making Table (page 21) for detailed requirements for each level of MDM.

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 2024 Evaluation and Management Office or Other Outpatient Services
– Time
Using Time as the determining factor:
• Includes total time spent by the physician or other qualified healthcare professional (face-to-face and
non-face-to-face on the same date of service)
Activities Included in Total Time:
• Preparing to see the patient (e.g., review of tests)
• Obtaining and / or reviewing separately attained history
• Performing a medically appropriate examination and / 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 / caregiver
• Care coordination (not separately reported)
Activities NOT Included in Total Time:
• Time spent on separately reported services such as minor procedures, diagnostic studies, or any
service reported on the same date of service
• Activities performed by clinical staff such as vital signs, recording history, etc.

Time Ranges for Office or Other Outpatient Visits

New Patient Established Patient
Code Time Threshold Code Time Threshold
99202 15 minutes met or exceeded 99212 10 minutes met or exceeded
99203 30 minutes met or exceeded 99213 20 minutes met or exceeded
99204 45 minutes met or exceeded 99214 30 minutes met or exceeded
99205 60 minutes met or exceeded 99215 40 minutes met or exceeded

Prolonged Services Codes

• May only be used when time is the determining factor
• May only be used with Level 5 codes – 99205 and 99215
• Fifteen-minute increments

Time Ranges for Prolonged Service Codes*

Total Duration of New Patient Visit Code(s) Reported
<75 minutes Report appropriate E&M code 99205
75 – 89 minutes 99205 x 1 and 99417 x 1
90 – 104 minutes 99205 x 1 and 99417 x 2
105 + minutes 99205 x 1 and 99417 x 3 + 1 for ea add’l 15 min
Total Duration of Established Patient Visit Code(s) Reported *CMS guidelines
<55 minutes Report appropriate E&M code 99215 differ from AMA
guidelines. Use
55 – 69 minutes 99215 x 1 and 99417 x 1 CMS guidelines
when reporting
70 – 84 minutes 99215 x 1 and 99417 x 2 to Medicare /
85 + minutes 99215 x 1 and 99417 x 3 + 1 for ea add’l 15 min Medicaid.

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 Critical Care Coding
99291: Critical care for the first 30–74 minutes
99292: Each additional 30 minutes beyond the first 74 minutes

AMA Guidelines
Total Duration Codes
Less than 30 minutes 99232 or 99233 or other appropriate E&M code
30 > 74 minutes 99291 (1 unit)
75 > 104 minutes 99291 (1 unit) and 99292 (1 unit)
105 > 134 minutes 99291 (1 unit) and 99292 (2 units)
135 > 164 minutes 99291 (1 unit) and 99292 (3 units)
165 > 194 minutes 99291 (1 unit) and 99292 (4 units)
194 minutes or longer 99291–99292 as appropriate per above illustrations

CMS Guidelines
Total Duration Codes
Less than 30 minutes 99232 or 99233 or other appropriate E&M code
30 > 103 minutes 99291 (1 unit)
104 > 133 minutes 99291 (1 unit) and 99292 (1 unit)
134 > 163 minutes 99291 (1 unit) and 99292 (2 units)
164 > 193 minutes 99291 (1 unit) and 99292 (3 units)
194 minutes or longer 99291–99292 as appropriate per above illustrations

Critical Care is defined as:

• The critical illness or injury acutely impairs one or more vital organ systems, with a high probability
of imminent or life-threatening deterioration in the patient’s condition.
• Involves high complexity decision making to assess, manipulate, and support vital system
function(s) to treat vital organ system failure or to prevent further life-threatening deterioration of
the patient’s condition.
• Requires direct delivery of medical care for a critically ill or critically injured patient by a
physician(s).
• Treatment and management of a patient’s condition, in the threat of imminent deterioration, while
not necessarily emergent, is required.
• Both the illness or injury and the treatment provided must meet the above requirements.

− Providing medical care to a critically ill patient should not be automatically deemed a
critical care service for the sole reason that the patient is critically ill or injured.

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 Critical Care Coding, Continued
• Time with family members may be counted towards critical care if:

− Patient is unable to participate in giving a history or making treatment decisions and

− Discussion is necessary for determining treatment

 All other family discussions, no matter how lengthy may not be counted towards
critical care

The following services are bundled into critical care and counted towards critical care time when
performed by the physician and cannot reported separately:

CPT Description
93561, 93562 Interpretation of cardiac output measurements
91010, 71015, 71020 Chest x-rays, Professional component
36415 Blood draw for specimen
99090 Blood gases, and information data stored in computers
– e.g., ECGs, blood pressures, hematologic data
43752, 43753 Gastric intubation
94760, 94761, 94762 Pulse oximetry
92953 Temporary transcutaneous pacing
94002 – 92004, 94660, 94662 Ventilator management
36000, 36410, 36415, 36591, 36600 Vascular access procedures

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 Critical Care Documentation
Documentation should include the following:
• The critical and unstable nature of the patient’s condition
• Complexity of medical decision making
• Aggregation of time spent by the billing provider, if applicable
• Patient assessment
• Family discussions – substance of discussion
• Total time spent

Note: Critical care services do qualify for shared/split care.

Critical Care Examples

Examples where medical condition(s) may warrant critical care services:
• A 69-year-old male patient is 4 days status post mitral valve repair. He develops hypotension,
hypoxia and petechiae, required respiratory and circulatory support.
• A 71 year old admitted for an acute anterior wall myocardial infarction and continues to have
symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy.

Examples where medical condition(s) may not warrant critical care services:
• Daily management of patient on chronic ventilator therapy
• Patients admitted to a critical care unit for close nursing observation and/or frequent monitoring of
vital signs (e.g., overdose, drug toxicity)
• Patients admitted to a critical care unit because hospital rules require certain treatments to be
administer in the critical care unit

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 Split / Shared Services
What is a Split / Shared service? CMS: How are Split / Shared services
documented and billed?
Defined by CMS as Evaluation and Management
visits (only) provided in the facility setting and • Documentation must identify the two
performed jointly by a physician and an NPP in the practitioners who performed the visit
same group practice on the same calendar day. • Visit must be billed by the practitioner
Patients may be new or established. who provides the substantive portion of
the visit
In what Places of Service (POS) are Split / Shared
− When both providers document time,
services allowed?
the times will be added together and
the provider with greater than 50% of
Allowed POS the total time is the billing provider
Provider-Based / Outpatient Clinics 19, 22
Hospital Inpatient (admission, OR
21
follow-up, discharge) − The provider who performs and
Observation 22 documents the MDM
Emergency Department 23 − The substantive component must be
Skilled Nursing/Nursing Facility 31, 32, 54, 56 performed in full by the billing
Critical Care Any POS practitioner
Prolonged Services Any POS except 11 − The practitioner providing the
substantive portion must sign and
Not Allowed POS date
Office visits 11
• CMS Guideline: Use -FS modifier to
Consults Any POS
denote E&M visit split or shared
Mandated Nursing Home visits 31, 32, 54, 56 between physician and non-physician
provider in same group

CMS Indicates:
Coming in 2025
All Split / Shared E&M Visits will be based on time.

AMA differences from CMS:

• The substantive portion can be determined by the provider who spent more than 50% of the time
OR who made or approved the MDM
• AMA does not provide any guidance on place of service where shared / split care can be provided
• Review CPT guidelines if utilizing data to support the level of service

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 Guidelines For Selecting Level of Service Based on Medical
Decision Making
Medical Decision Making (MDM) includes establishing diagnoses, assessing the status of a
condition, and/or selecting a management option. MDM is defined by three elements.

The elements are:

• The number and complexity of problem(s) that are addressed during the encounter.
• The amount and/or complexity of data to be reviewed and analyzed. These data include medical
records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed
for the encounter. This includes information obtained from multiple sources or interprofessional
communications that are not reported separately and interpretation of tests that are not reported
separately. Ordering a test is included in the category of test result(s) and the review of the test
result is part of the encounter and not a subsequent encounter. Ordering a test may include those
considered but not selected after shared decision making. For example, a patient may request
diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit
may be required. Alternatively, a test may normally be performed, but due to the risk for a specific
patient it is not ordered. These considerations must be documented. Data are divided into three
categories:

− Tests, documents, orders, or independent historian(s). (Each unique test, order, or

document is counted to meet a threshold number.)
− Independent interpretation of tests (not separately reported).
− Discussion of management or test interpretation with external physician or other qualified
health care professional or appropriate source (not separately reported).

• The risk of complications and/or morbidity or mortality of patient management. This includes
decisions made at the encounter associated with diagnostic procedure(s) and treatment(s). This
includes the possible management options selected and those considered but not selected after
shared decision making with the patient and/or family. For example, a decision about
hospitalization includes consideration of alternative levels of care. Examples may include a
psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to
not hospitalize a patient with advanced dementia with an acute condition that would generally
warrant inpatient care, but for whom the goal is palliative treatment.

Shared decision making involves eliciting patient and/or family preferences, patient and/or family
education, and explaining risks and benefits of management options. MDM may be impacted by role and
management responsibility.

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 When the physician or other qualified health care professional is reporting a separate CPT code that
includes interpretation and/or report, the interpretation and/or report is not counted toward the MDM when
selecting a level of E&M services. When the physician or other qualified health care professional is
reporting a separate service for discussion of management with a physician or another qualified health care
professional, the discussion is not counted toward the MDM when selecting a level of E&M services.

The Levels of Medical Decision Making (MDM) table is a guide to assist in selecting the level of MDM for
reporting an E&M services code. The table includes the four levels of MDM (i.e., straightforward, low,
moderate, high) and the three elements of MDM (i.e., number and complexity of problems addressed at the
encounter, amount and/or complexity of data reviewed and analyzed, and risk of complications and/or
morbidity or mortality of patient management). To qualify for a particular level of MDM, two of the three
elements for that level of MDM must be met or exceeded.

Examples in the table may be more or less applicable to specific settings of care. For example, the decision
to hospitalize applies to the outpatient or nursing facility encounters, whereas the decision to escalate
hospital level of care (e.g., transfer to ICU) applies to the hospitalized or observation care patient. See also
the introductory guidelines of each code family section.

Number and Complexity of Problems Addressed at the Encounter

One element used in selecting the level of service is the number and complexity of the problems that are
addressed at the encounter. Multiple new or established conditions may be addressed at the same time
and may affect MDM. Symptoms may cluster around a specific diagnosis and each symptom is not
necessarily a unique condition. Comorbidities and underlying diseases, in and of themselves, are not
considered in selecting a level of E&M services unless they are addressed, and their presence increases the
amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or
morbidity or mortality of patient management. The final diagnosis for a condition does not, in and of itself,
determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the
signs or symptoms do not represent a highly morbid condition. Therefore, presenting symptoms that are
likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not
highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition.
Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

The term “risk” as used in these definitions relates to risk from the condition. While condition risk and
management risk may often correlate, the risk from the condition is distinct from the risk of the
management.

Definitions for the elements of MDM are:

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 Problem: A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other
matter addressed at the encounter, with or without a diagnosis being established at the time of the
encounter.

Problem Addressed: A problem is addressed or managed when it is evaluated or treated at the encounter
by the physician or other qualified health care professional reporting the service. This includes
consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or
patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another
professional is managing the problem without additional assessment or care coordination documented
does not qualify as being ‘addressed’ or managed by the physician or other qualified health care
professional reporting the service. Referral without evaluation (by history, exam, or diagnostic study[ies]) or
consideration of treatment does not qualify as being addressed or managed by the physician or other
qualified health care professional reporting the service.

Minimal Problem: A problem that may not require the presence of the physician or other qualified health
care professional, but the service is provided under the physician’s or other qualified health care
professional’s supervision (see 99211).

Self-Limited Or Minor Problem: A problem that runs a definite and prescribed course, is transient in
nature, and is not likely to permanently alter health status.

Stable, Chronic Illness: A problem with an expected duration of at least a 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 (e.g., uncontrolled diabetes and controlled diabetes are a single chronic condition).
‘Stable’ for the purposes of categorizing medical decision making is defined by the specific treatment goals
for an individual patient. A patient that is not at their treatment goal is not stable, even if the condition has
not changed and there is no short-term threat to life or function. For example, a patient with persistently
poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not
changing and the patient is asymptomatic. The risk of morbidity without treatment is significant. Examples
may include well-controlled hypertension, non-insulin dependent diabetes, cataract, or benign prostatic
hyperplasia.

Acute, Uncomplicated Illness or Injury: 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. Examples may include
cystitis, allergic rhinitis, or a simple sprain.

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 Acute Illness with Systemic Symptoms: An illness that causes systemic symptoms and has a high risk of
morbidity without treatment. For systemic general symptoms such as fever, body aches or fatigue in a
minor illness that may be treated to alleviate symptoms, shorten the course of illness or to prevent
complications, see the definitions for ‘self-limited or minor’ or ‘acute, uncomplicated.’ Systemic symptoms
may not be general but may be single system. Examples may include pyelonephritis, pneumonitis, or colitis.

Acute, Complicated Injury: An injury which requires treatment that includes evaluation of body systems
that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple
and/or associated with risk of morbidity. An example may be a head injury with brief loss of consciousness.

Chronic Illness with Exacerbation, Progression, or Side Effects of 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, but that does not require
consideration of hospital level of care

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 hospital level of care.

Acute or Chronic Illness or Injury That Poses a Threat to Life or Bodily Function: An acute illness with
systemic symptoms, or an acute complicated injury, or a chronic illness or injury with exacerbation and/or
progression or side effects of treatment, which poses a threat to life or bodily function in the near term
without treatment. Examples may include acute myocardial infarction, pulmonary embolus, severe
respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self
or others, peritonitis, acute renal failure, or an abrupt change in neurologic status.

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. An example may be a
lump in the breast.

Amount and/or Complexity of Data to Be Reviewed and Analyzed

One element used in selecting the level of services is the amount and/or complexity of data to be reviewed
or analyzed at an encounter.

Analyzed: The process of using the data as part of the MDM. The data element itself may not be subject to
analysis (e.g., glucose), but it is instead included in the thought processes for diagnosis, evaluation, or
treatment. Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they
are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an
encounter may be counted in the encounter in which they are analyzed. In the case of a recurring order,
each new result may be counted in the encounter in which it is analyzed. For example, an encounter that

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 includes an order for monthly prothrombin times would count for one prothrombin time ordered and
reviewed. Additional future results, if analyzed in a subsequent encounter, may be counted as a single test
in that subsequent encounter. Any service for which the professional component is separately reported by
the physician or other qualified health care professional reporting the E&M services is not counted as a
data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining
the level of MDM.

Test: Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (e.g.,
basic metabolic panel [80047]) is a single test. The differentiation between single or multiple tests is
defined in accordance with the CPT code set. For the purpose of data reviewed and analyzed, pulse
oximetry is not a test.

Unique: A unique test is defined by the CPT code set. When multiple results of the same unique test (e.g.,
serial blood glucose values) are compared during an E&M service, count it as one unique test. Tests that
have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example,
a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet
count. A unique source is defined as a physician or other qualified health care professional in a distinct
group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique
source counts as one element toward MDM.

Combination of Data Elements: A combination of different data elements, for example, a combination of
notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be
summed. It does not require each item type or category to be represented. A unique test ordered, plus a
note reviewed and an independent historian would be a combination of three elements.

External: External records, communications and/or test results are from an external physician, other
qualified health care professional, facility, or health care organization.

External Physician or Other Qualified Health Care Professional: An external physician or other qualified
health care professional who is not in the same group practice or is of a different specialty or subspecialty.
This includes licensed professionals who are practicing independently. The individual may also be a facility
or organizational provider such as from a hospital, nursing facility, or home health care agency.

Discussion: Discussion requires an interactive exchange. The exchange must be direct and not through
intermediaries (e.g., clinical staff or trainees). Sending chart notes or written exchanges that are within
progress notes does not qualify as an interactive exchange. The discussion does not need to be on the date
of the encounter, but it is counted only once and only when it is used in the decision making of the
encounter. It may be asynchronous (i.e., does not need to be in person), but it must be initiated and
completed within a short time period (e.g., within a day or two).

Independent Historian(s): An individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a
history in addition to a history provided by the patient who is unable to provide a complete or reliable

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 history (e.g., due to developmental stage, dementia, or psychosis) or because a confirmatory history is
judged to be necessary. In the case where there may be conflict or poor communication between multiple
historians and more than one historian is needed, the independent historian requirement is met. It does not
include translation services. The independent history does not need to be obtained in person but does need
to be obtained directly from the historian providing the independent information.

Independent Interpretation: The interpretation of a test for which there is a CPT code, and an
interpretation or report is customary. This does not apply when the physician or other qualified health care
professional who reports the E&M service is reporting or has previously reported the test. A form of
interpretation should be documented but need not conform to the usual standards of a complete report for
the test.

Appropriate Source: For the purpose of the discussion of management data element an appropriate source
includes professionals who are not health care professionals but may be involved in the management of the
patient (e.g., lawyer, parole officer, case manager, teacher). It does not include discussion with family or
informal caregivers.

Risk of Complications and/or Morbidity or Mortality of Patient Management

One element used in selecting the level of service is the risk of complications and/or morbidity or mortality
of patient management at an encounter. This is distinct from the risk of the condition itself.

Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by
the nature of the event under consideration. For example, a low probability of death may be high risk,
whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of
risk are based upon the usual behavior and thought processes of a physician or other qualified health care
professional in the same specialty. Trained clinicians apply common language usage meanings to terms
such as high, medium, low, or minimal risk and do not require quantification for these definitions (though
quantification may be provided when evidence-based medicine has established probabilities). For the
purpose of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter
when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing,
treatment, and/or hospitalization. The risk of patient management criteria applies to the patient
management decisions made by the reporting physician or other qualified health care professional as part
of the reported encounter.

Morbidity: A state of illness or functional impairment that is expected to be of substantial duration during
which function is limited, quality of life is impaired, or there is organ damage that may not be transient
despite treatment.

Social Determinants of Health: Economic and social conditions that influence the health of people and
communities. Examples may include food or housing insecurity.

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 Surgery (minor or major, elective, emergency, procedure or patient risk):

Surgery—Minor or Major: The classification of surgery into minor or major is based on the common
meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms
are not defined by a surgical package classification.

Surgery—Elective or Emergency: Elective procedures and emergent or urgent procedures describe the
timing of a procedure when the timing is related to the patient’s condition. An elective procedure is
typically planned in advance (e.g., scheduled for weeks later), while an emergent procedure is typically
performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent
procedures may be minor or major procedures.

Surgery—Risk Factors, Patient or Procedure: Risk factors are those that are relevant to the patient and
procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and
procedure risk.

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. The
monitoring should be that which is generally accepted practice for the agent but may be patient-specific in
some cases. Intensive monitoring may be long-term or short-term. Long-term intensive monitoring is not
performed less than quarterly. The monitoring may be performed with a laboratory test, a physiologic test,
or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of MDM
in an encounter in which it is considered in the management of the patient. An example may be monitoring
for cytopenia in the use of an antineoplastic agent between dose cycles. Examples of monitoring that do not
qualify include monitoring glucose levels during insulin therapy, as the primary reason is the therapeutic
effect (unless severe hypoglycemia is a current, significant concern); or annual electrolytes and renal
function for a patient on a diuretic, as the frequency does not meet the threshold.

Source: CPT Professional 2024

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 Code Selection Requires 2 of 3 Elements be Met (Complexity, Data to Review, Risk)

Complexity Data to Review Risk

Straightforward: Minimal: Minimal risk of morbidity from additional diagnostic testing or
1 self-limited or minor problem No data treatment

Low Complexity: Limited (meet 1 of 2 categories) Low risk of morbidity from additional diagnostic testing or treatment
2 or more self-limited or minor problems OR Category 1: Tests and Documents
1 stable chronic illness OR Any combination of 2 from the following:
1 acute, uncomplicated illness or injury OR □ Review of prior external note(s) from each unique source
1 stable, acute illness OR □ Review of the result(s) of each unique test
1 acute, uncomplicated illness or injury requiring hospital inpatient □ Ordering of each unique test
or observation level of care OR
Category 2: Assessment requiring an independent historian

Moderate Complexity: Moderate (meet 1 of 3 categories) Moderate risk of morbidity from additional diagnostic testing or
2 or more stable chronic illnesses OR Category 1: Tests and Documents treatment
1 or more chronic illness with exacerbation, progression of side Any combination of 3 from the following
effect OR □ Review of prior external note(s) from each unique source Examples only:
1 undiagnosed new problem with uncertain prognosis OR □ Review of the result(s) of each unique test • Prescription drug management
1 acute illness with systemic symptoms OR □ Ordering of each unique test • Decision regarding minor surgery with identified patient or
1 acute complicated injury □ Assessment requiring an independent historian(s) procedure risk factors
OR • Decision regarding elective major surgery without identified
Category 2: Independent Interpretation of test (performed by another patient or procedure risk factors
physician / not reported separately) • Diagnosis or treatment significantly limited by social
OR determinants of health
Category 3: Discussion of management or test interpretation with external
physician and/or appropriate source

High Complexity: Extensive (meet 2 of 3 categories) High risk of morbidity from additional diagnostic testing or treatment
1 or more chronic illness with severe exacerbation, progression of Category 1: Tests and Documents:
side effect OR Any combination of 3 from the following: Examples only:
1 acute or chronic illness or injury posing a threat to life or bodily □ Review of prior external note(s) from each unique source • Drug therapy requiring intensive monitoring for toxicity
function □ Review of the result(s) of each unique test • Decision regarding elective major surgery with identified
□ Ordering of each unique test patient or procedure risk factors
□ Assessment requiring an independent historian(s) • Decision regarding emergency major surgery
OR • Decision regarding hospitalization or escalation of hospital-
Category 2: Independent Interpretation of test (performed by another level care
physician / not reported separately) • Decision not to resuscitate or to de-escalate care because of
OR poor prognosis
Category 3: Discussion of management or test interpretation with external • Decision regarding parenteral controlled substances
physician/appropriate source

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