The Centers for Medicare & Medicaid Services (CMS) recently updated its Evaluation and Management (E/M) Services Guide. The updates reflect changes to the hospital inpatient and observation care, home or residence, nursing facility, and emergency department (ED) E/M services that took effect earlier this year.
Beginning Jan. 1, CMS revised the documentation guidelines for E/M services in these settings to make them more like the 2021 updates to the office visit E/M guidelines. Under the new guidelines, clinicians can usually select the level of service using either medical decision making (MDM) or total time on the date of the encounter (the exception is ED services, which can only be selected based on MDM). As with office E/M, total time now includes both face-to-face and non-face-to-face time the physician or other qualified health care professional personally spends on the visit on the date of service. A medically appropriate history and physical exam should be performed and documented, but they are no longer used to determine the level of service.
In general, CMS aligns with the American Medical Association’s CPT E/M code descriptors and guidelines. However, a key difference between CMS and CPT is the time requirements for billing prolonged services. The new guide includes more information on how to code for prolonged services in the hospital/outpatient setting for Medicare patients as well as a table outlining the time thresholds for each prolonged service code. Although there were no updates to prolonged service codes for office/outpatient E/M services, they are also listed below for easy reference.
| Primary E/M service* | Prolonged service code | Time threshold | Timeframe counted |
Initial inpatient or observation visit (99223) |
G0316 |
90 minutes |
Date of visit |
Subsequent inpatient or observation (99233) |
G0316 |
65 minutes |
Date of visit
|
Inpatient or observation same-day admission or discharge (99236) |
G0316 |
110 minutes |
Date of visit to 3 days after |
Initial nursing facility visit (99306) |
G0317 |
95 minutes |
1 day before visit, date of visit, and 3 days after |
Subsequent nursing facility visit (99310) |
G0317 |
85 minutes |
1 day before visit, date of visit, and 3 days after |
New patient home or residence visit (99345) |
G0318 |
140 minutes |
3 days before visit, date of visit, and 7 days after |
Established patient home or residence visit (99350) |
G0318 |
110 minutes |
3 days before visit, date of visit, and 7 days after |
Cognitive assessment and care planning (99483) |
G2212 |
100 minutes |
3 days before visit, date of visit, and 7 days after |
* Prolonged services can not be billed for emergency department visits, hospital or nursing facility discharge day management, or consults
| Codes | Total time required for reporting |
99205 x 1 and G2212 x 1 |
89-103 minutes |
99205 x 1 and G2212 x 2 |
104-118 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 each additional 15 minutes |
99 or more |
The updated guide also includes details on billing for critical care, split/shared services, chronic pain management, and teaching physician services.
— Erin Solis, AAFP Manager of Practice & Payment
Posted on Sept. 12, 2023
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