Find the total time and medical decision making levels for a variety of E/M codes and service areas.
Total time and MDM do not apply to 99211. CPT code 99211 is intended for the evaluation and management of a patient that may not require the presence of a physician or other QHP.
| Office or Other Outpatient Services | ||
|---|---|---|
| CPT Code | MDM | Timing (must be met or exceed) |
99202 |
Straightforward |
15 minutes |
99203 |
Low |
30 minutes |
| 99204 | Moderate | 45 minutes |
| 99205 | High | 60 minutes |
99212 |
Straightforward |
10 minutes |
99213 |
Low |
20 minutes |
99214 |
Moderate |
30 minutes |
99215 |
High |
40 minutes |
| Prolonged Services | ||
| +99417 | 75 minutes | |
| G2212 | 89 minutes | |
Total time and MDM do not apply to 99211. CPT code 99211 is intended for the evaluation and management of a patient that may not require the presence of a physician or other QHP.
The observation CPT codes (99217, 99218, 99219, 99220, 99224, 99225, 99226) have been deleted and merged into the existing hospital care CPT codes.
| Initial hospital inpatient or observation care | ||
|---|---|---|
| Code | MDM | Time Range (must be met or exceeded) |
99221 |
Straightforward or low |
40 minutes |
99222 |
Moderate |
55 minutes |
99223 |
High |
75 minutes |
Prolonged Services |
||
+99418 |
-- |
90 minutes or longer |
G0316 |
-- |
105 minutes or longer |
| Subsequent hospital inpatient or observation care | ||
|---|---|---|
| Code | MDM | Time (must be met or exceeded) |
99231 |
Straightforward or low |
25 minutes |
99232 |
Moderate |
35 minutes |
99233 |
High |
50 minutes |
| Prolonged Services | ||
+99418 |
-- |
65 minutes or longer |
G0316 |
-- |
80 minutes or longer |
Initial vs. subsequent is determined based on whether the patient has received any professional services from the physician or other QHP or another physician or other QHP of the exact same specialty and subspecialty who belongs to the same group practice during the stay. This is like the new vs. established patient definitions, except the determining factor is related to the stay rather than the past three years.
| Hospital inpatient or discharge services (including admission and discharge services) | ||
|---|---|---|
| Code | MDM | Time (must be met or exceeded) |
99234 |
Straightforward or low |
45 minutes |
99235 |
Moderate |
70 minutes |
99236 |
High |
85 minutes |
| Prolonged Services | ||
+99418 |
-- |
100 minutes or longer |
G0316 |
-- |
125 minutes or longer* |
*Total time within 3 calendar days of the encounter.
| Hospital inpatient or observation discharge services | ||
|---|---|---|
| Code | MDM | Time |
99238 |
— |
30 minutes or less |
99239 |
— |
More than 30 minutes |
Time includes total time on the date of the encounter.
Hospital Inpatient or Observation Care Services require that the patient be admitted and discharged on the same date of service and the stay must be at least eight hours. Only the physician or QHP who performs both the initial and discharge service may report these services. When a patient receives hospital inpatient or observation care services for fewer than eight hours, use the initial hospital inpatient or observation care codes (CPT codes 99221-99223).
Most of the guidelines for the consultation codes remain the same. Code descriptors have been edited to reflect the revised MDM and time requirements. Note: Medicare does not cover consultation codes.
| Office or Other Outpatient Consultations – New or Established | ||
|---|---|---|
| Code | MDM | Time (must be met or exceeded) |
99241 (Deleted) |
-- |
-- |
99242 |
Straightforward |
20 minutes |
99243 |
Low |
30 minutes |
99244 |
Moderate |
40 minutes |
99245 |
High |
55 minutes |
Prolonged Services |
||
+99417 |
-- |
70 minutes or longer |
| Inpatient or Observation Consultations – New or Established | ||
|---|---|---|
| Code | MDM | Time (must be met or exceeded) |
99251 (Deleted) |
-- |
-- |
99252 |
Straightforward |
35 minutes |
99253 |
Low |
45 minutes |
99254 |
Moderate |
60 minutes |
99255 |
High |
80 minutes |
Prolonged Services |
||
+99418 |
-- |
95 minutes or longer |
Time cannot be used to select the level of service for emergency department visits. The level of service is based on MDM. This does not differ from the previous guideline. However, the MDM levels have been modified to align with those for office visits.
| Emergency Department Services – New or Established Patient | |
|---|---|
| Code | MDM |
99281 |
-- |
99282 |
Straightforward |
99283 |
Low |
99284 |
Moderate |
99285 |
High |
MDM does not apply to 99281. CPT 99281 is intended for the evaluation and management of a patient that may not require the presence of a physician or other QHP.
| Initial Nursing Facility Care – New or Established Patient | ||
|---|---|---|
| Code | MDM | Time (must be met or exceeded) |
99304 |
Straightforward or low |
25 minutes |
99305 |
Moderate |
35 minutes |
99306 |
High |
50 minutes |
Prolonged Services |
||
+99418 |
-- |
60 minutes or longer |
G0317 |
-- |
95 minutes or longer* |
*Total time 1 day before visit + date of visit + 3 days after
| Nursing Facility Discharge Service | ||
|---|---|---|
| Code | MDM | Time (must be met or exceeded) |
99315 |
-- |
30 minutes or less total time |
99316 |
-- |
More than 30 minutes |
Nursing facility discharge services require a face-to-face encounter with the patient and/or family/caregiver that may be performed on a date prior to the date the patient leaves the facility. The level of service should be selected based on the total time on the date of the face-to-face discharge management encounter.
The CPT code for annual nursing facility assessment (CPT code 99318) has been deleted. These services can be reported using the subsequent nursing facility care services (CPT codes 99307-99310) or Medicare G codes.
| Subsequent Nursing Facility Care | ||
|---|---|---|
| Code | MDM | Time (must be met or exceeded) |
99307 |
Straightforward |
10 minutes |
99308 |
Low |
20 minutes |
99309 |
Moderate |
30 minutes |
99310 |
High |
45 minutes |
Prolonged Services |
||
+99418 |
-- |
60 minutes or longer |
G0317 |
-- |
85 minutes or longer* |
*Total time 1 day before visit + date of visit + 3 days after
The CPT Panel established a high-level MDM type specific to initial nursing facility care by the principal physician or other QHP that takes into account the number and complexity of problems addressed. This type is: "Multiple morbidities requiring intensive management: A set of conditions, syndromes, or functional impairments that are likely to require frequent medication changes or other treatment changes and/or re-evaluations. The patient is at significant risk of worsening medical (including behavioral) status and risk for (re)admission to a hospital.”
A principal physician is sometimes referred to as the admitting physician and is the individual who oversees the patient’s care. This is different from other physicians or other QHPs who may be furnishing specialty care.
Initial vs. subsequent is determined based on whether the patient has received any professional services from the physician or other QHP or another physician or other QHP of the exact same specialty and subspecialty who belongs to the same group practice during the stay. This is like the new vs. established patient definitions, except the determining factor is related to the stay rather than the past three years.
The domiciliary or rest home CPT codes (99334-99340) have been deleted and merged with the existing home visit CPT codes (99341-99350).
| Home or Residence Services – New Patient | ||
|---|---|---|
| Code | MDM | Time (must be met or exceeded) |
99341 |
Straightforward |
15 minutes |
99342 |
Low |
30 minutes |
99343 (Deleted) |
-- |
-- |
99344 |
Moderate |
60 minutes |
99345 |
High |
75 minutes |
Prolonged Services |
||
+99417 |
-- |
90 minutes or longer |
G0318 |
-- |
141 minutes or longer* |
*Total time 3 days before visit + date of visit + 7 days after
| Home or Residence Services – Established Patient | ||
|---|---|---|
| Code | MDM | Time (must be met or exceeded) |
99347 |
Straightforward |
20 minutes |
99348 |
Low |
30 minutes |
99349 |
Moderate |
40 minutes |
99350 |
High |
60 minutes |
Prolonged Services |
||
+99417 |
-- |
75 minutes or longer |
G0318 |
-- |
112 minutes or longer* |
*Total time 3 days before visit + date of visit + 7 days after