Evaluation and Management (E&M) codes are to be performed by physicians, nurse practitioners and physician assistants. Physician codes should be billed using the rendering provider’s individual NPI.
99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s)
are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
Billing Instructions: Bill 1 unit per visit.
99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
Billing Instructions: Bill 1 unit per visit.
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity.
Typically, 30 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.
99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
Billing Instructions: Bill 1 unit per visit.
99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.
99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.
Billing Instructions: Bill 1 unit per visit.
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting Problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
Billing Instructions: Bill 1 unit per visit.
99213
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.
99214
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
Billing Instructions: Bill 1 unit per visit.
99215
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-toface with the patient and/or family.
Billing Instructions: Bill 1 unit per visit.
99217
Observation care discharge day management. Billing Instructions: This code is to be utilized to report all services provided to a patient on discharge from “observation status” if the discharge is on other than the initial date of “observation status.” To report services to a patient designated as “observation status” or “inpatient status” and discharged on the same date, us the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]
99218 Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problems(s) requiring admission to “observation status” are of low severity. Typically, 30 minutes are spent at the bedside and on the patient’s hospital floor or unit.
99219
initial observation care, per day, for the evaluation and management of a patient which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problems(s) requiring
admission to “observation status” are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient’s hospital floor or unit.
99220
Initial observation care, per day, for the evaluation and management of a patient, which requires these three components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problems(s) and the patient’s and/or family’s needs. Usually the problem(s) requiring admission to “observation status” are of high severity. Typically, 70 minutes are spent at the bedside and on the patient’s hospital floor or unit.
90833 Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (Use only as an add-on to the appropriate CPT code.)
90836 Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (Use only as an add-on to the appropriate CPT code.)
90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (Use only as an add-on to the appropriate CPT code.)
When a beneficiary receives an Evaluation and Management Service (E&M) service with a psychotherapeutic service on the same day, by the same provider, both services are payable if they are significant and separately identifiable and billed using the correct codes. New add-on codes (in the bulleted list below) designate psychotherapeutic services performed with E&M codes. An add-on code (often designated with a “+” in codebooks) describes a service performed with another primary service. An add-on code is eligible for payment only if reported with an appropriate primary service performed on the same date of service. Time spent for the E&M service is separate from the time spent providing psychotherapy and time spent providing psychotherapy cannot be used to meet criteria for the E&M service. Because time is indicated in the code descriptor for the psychotherapy CPT codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.
For psychotherapy services provided with an E&M service:
• Code + 90833: Psychotherapy, 30 minutes with patient and/or family member when performed with an E&M service (list separately in addition to the code for primary procedure)
• Code + 90836: Psychotherapy, 45 minutes with patient and/or family member when performed with an E&M service (list separately in addition to the code for primary procedure)
• Code + 90838: Psychotherapy, 60 minutes with patient and/or family member when performed with an E&M service (list separately in addition to the code for primary procedure)
For psychotherapy services provided without an E&M service, the correct code depends on the time spent with the beneficiary.
• Code 90832: Psychotherapy, 30 minutes with patient and/or family member
• Code 90834: Psychotherapy, 45 minutes with patient and/or family member
• Code 90837: Psychotherapy, 60 minutes with patient and/or family member
In general, providers should select the code that most closely matches the actual time spent performing psychotherapy. CPT® provides flexibility by identifying time ranges that may be associated with each of the three codes:
• Code 90832 (or + 90833): 16 to 37 minutes,
• Code 90834 (or + 90836): 38 to 52 minutes, or
• Code 90837 (or + 90838): 53 minutes or longer
Do not bill psychotherapy codes for sessions lasting less than 16 minutes.
Psychotherapy codes are no longer dependent on the service location (i.e., office, hospital, residential setting, or other location is not a factor). However, effective January 1, 2014, when E&M services are paid under Medicare’s Partial Hospitalization Program (PHP) and not in the physician office setting, the CPT outpatient visit codes 99201-99215 have been replaced with one Level II HCPCS code – G0463. Further information about this code can be found in the CY 2014 OPPS/ASC final rule that was published in the Federal Register on December 10, 2013.
