Key point to remember
As stated in the Centers for Medicare & Medicaid Services (CMS) Internet-only Manuals (IOM) 100-04, Chapter 12, Section 30.6.1:
Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.
The key components (elements of service) of evaluation & management (E/M) services are:
3. Medical decision-making
When counseling and/or coordination of care dominates (more than 50%) 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.
Tips pertaining to different types of E/M services can be located by accessing the links in the table below:
CPT code range Type of E/M service
99201-99205 Office or other outpatient E/M services for new patients
99211-99215 Office or other outpatient E/M services for established patients
99221-99223 Initial hospital care E/M services
99231-99233 Subsequent hospital care E/M services
96150-96152, G0425-G0427 Telehealth Services Medicare Payment for Telehealth services
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