time guideline for 99211, 99212, 99213, 99214, 99215 - E & M code

Evaluation & management tips: Office or other outpatient services, established patient

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:

1. History
2. Examination
3. Medical decision-making.

When billing office or other outpatient services for established patients, two of the three key components must be fully documented in order to bill (other than 99211). When counseling and/or coordination of care dominates (more than 50 percent) the physician patient and/or family encounter (face-to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.

Current Procedural Terminology (CPT) codes and requirements

99211 - 5 minutes (average)
• Patient presenting with minimal problems
• Three components not required


99212 - 10 minutes (average)

• Problem focused history. Documentation needed:
• Chief complaint
• Brief history of present illness
• Problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system
• Medical decision making that is straightforward. Documentation needed (two of three below must be met or exceeded):
• Minimal number of diagnoses or management options
• None or minimal amount and/or complexity of data to be reviewed
• Minimal risk of significant complications, morbidity and/or mortality


99213 - 15 minutes (average)

• Expanded problem focused history. Documentation needed:
• Chief complaint
• Brief history of present illness
• Problem pertinent review of systems
• Expanded problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
• Medical decision making that is of low complexity. Documentation needed (two of three below must be met or exceeded):
• Limited number of diagnoses or management options
• Limited amount and/or complexity of data to be reviewed
• Low risk of significant complications, morbidity and/or mortality


99214 - 25 minutes (average)

• Detailed history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Extended review of systems
• Pertinent past, family and/or social history
• Detailed examination. Documentation needed:
• Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
• Medical decision making that is of moderate complexity. Documentation needed (two of three below must be met or exceeded):
• Multiple number of diagnoses or management options
• Moderate amount and/or complexity of data to be reviewed
• Moderate risk of significant complications, morbidity and/or mortality

99215 - 40 minutes (average)

• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history
• Comprehensive examination. Documentation needed:
• A general multi-system examination OR complete examination of single organ system and other symptomatic or related body area(s) or eight or more organ system(s)
• Medical decision making that is of high complexity. Documentation needed (two of three below must be met or exceeded):
• Extensive number of diagnoses or management options
• Extensive amount and/or complexity of data to be reviewed

• High risk of significant complications, morbidity and/or mortality

An important guideline to remember when reporting office visits other than counseling and coordination of care is that only two of the three key components must be reported. 

 The following is a summary of the requirements for codes 99211 – 99215.

99211: 5 minutes and may not require the presence of a physician

99212: 10 minutes
A problem focused history
A problem focused examination
Straight forward decision making

99213: 15 minutes
An expanded problem focused history
An expanded problem focused examination
Medical decision making of low complexity

99214: 25 minutes
A detailed history
A detailed examination
Medical decision making of moderate complexity

99215: 40 minutes
A comprehensive history
A comprehensive examination
Medical decision making of high complexity

History and physical examination skills and documentation guidelines we were taught in medical training tend to produce a very high quality of medical care. But these do not always meet the guidelines in the multiple medical record components that are required by CPT coding system for E/M coding. To be more efficient and improve reimbursements, physicians must have a better understanding of the Current Procedural Terminology requirements. Future discussions in this section of the AHS website will include a comprehensive discussion of the three key components of CPT coding: History, Examination, and Medical Decision Making, as well as a review of the importance of understanding the Nature of the Presenting Problem in ensuring proper coding. The fourth quarterly future topic in this series will be devoted to the International Classification of Diseases (ICD – 9-CM) coding.


Preoperative and Postoperative Billing Errors

Preoperative and postoperative billing errors occur when E&M services are billed with surgical procedures during their preoperative and postoperative periods. ClaimCheck bases the preoperative and postoperative periods on designations in the CMS National Physician Fee Schedule. For example, if a provider submits procedure code 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making [10 minutes]) with a DOS of 11/02/08 and procedure 27750 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; without manipulation) with a DOS of 11/03/08, ClaimCheck will deny procedure code 99212 as a preoperative visit because it is submitted with a DOS one day prior to the DOS for procedure code 27750.

Services Provided by Ancillary Providers

Claims for services provided through telemedicine by ancillary providers should continue to be submitted under the supervising physician's NPI (National Provider Identifier) using the lowest appropriate level office or outpatient visit procedure code or other appropriate CPT code for the service performed. These services must be provided under the direct on-site supervision of a physician and documented in the same manner as face-to-face services. Coverage is limited to procedure codes 99211 or 99212, as appropriate.

Primary Care Treatment and Follow-up Care for Mental Health and Substance Abuse

Initial primary care treatment and follow-up care are covered for members with mental health and/or substance abuse needs provided by primary care physicians, physician assistants, and nurse practitioners. Wisconsin Medicaid will reimburse the previously listed providers for CPT (Current Procedural Terminology) E&M (evaluation and management) services (procedure codes 99201-99205 and 99211-99215) with an ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code applicable for mental health and/or substance abuse services. As a reminder, these services may be eligible for HPSAs (Health Professional Shortage Areas) and pediatric enhanced reimbursements. Refer to the latest edition of CPT or to the CMS (Centers for Medicare and Medicaid Services) 1995 or 1997 Documentation Guidelines for Evaluation and Management Services via the CMS Web site for guidelines for determining the appropriate level of E&M services.

Since counseling may constitute a significant portion of the E&M services delivered to a member with mental health and/or substance abuse diagnoses, providers are required to fully document the percentage of the E&M time that involved counseling. This documentation is necessary to justify the level of E&M visit. Claims for services delivered by ancillary staff under the direct, on-site supervision of a primary care physician must be submitted under the NPI (National Provider Identifier) of the supervising physician. Coverage and reimbursement are limited to CPT code 99211 or 99212 as appropriate.

Tobacco Cessation Drugs and Services

Tobacco cessation services are reimbursed as part of an E&M (evaluation and management) office visit provided by a physician, physician assistant, nurse practitioner, and ancillary staff. Services must be one-on-one, face-to-face between the provider and the member. BadgerCare Plus does not cover group sessions or telephone conversations between the provider and member under the E&M procedure codes. Tobacco cessation services covered under BadgerCare Plus and Wisconsin Medicaid include outpatient substance abuse services or outpatient mental health services, as appropriate. Tobacco cessation services covered under the BadgerCare Plus Core Plan include medically necessary E&M visits, as appropriate.

Ancillary staff can provide tobacco cessation services only when under the direct, on-site supervision of a Medicaid-enrolled physician. When ancillary staff provide tobacco cessation services, BadgerCare Plus reimburses up to a level-two office visit (CPT (Current Procedural Terminology) code 99212). The supervising provider is required to be listed as the rendering provider on the claim.

Health Professional Shortage Area-Eligible Procedure Codes Providers may submit claims with HPSA modifier "AQ" (Physician providing a service in a HPSA). While the modifier is defined for physicians only, any Medicaid HPSA-eligible provider may use them with the following procedure codes

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