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Evaluation & Management Visits

This page contains guidance regarding documentation and payment under the Medicare Physician Fee Schedule for evaluation and management (E/M) visits.

• Physician Fee Schedule (PFS) Payment for Office/Outpatient Evaluation and Management (E/M) Visits – Fact Sheet (PDF) - Updated 01/14/2021
• Evaluation and Management (E/M) Visit Frequently Asked Questions (FAQs) (PDF)
• Evaluation and Management Services MLN Publication
• FAQs: Split (or Shared) Visits and Critical Care Services (PDF) :  Posted 4/7/2022

Medicare Part B (Medical Insurance)  covers E-visits with your doctors and certain other health care providers.

Your costs in Original Medicare

After you meet the Part B deductible , you pay 20% of the  Medicare-approved amount  for your doctor's or other provider's services.

E-visits allow you to talk to your doctor or other health care provider using an online patient portal to answer quick questions or decide if you need to schedule a visit.

You can get an E-visit with:

• Nurse practitioners
• Clinical nurse specialists
• Physician assistants
• Licensed clinical social workers (in specific circumstances)
• Clinical psychologists (in specific circumstances)

E-visits can be used for the treatment for the Coronavirus (COVID-19) from anywhere, including places of residence (like homes, nursing homes, and assisted living facilities).

Things to know

• To get an e-visit, you must request one with your doctor or other provider.
• Medicare also covers virtual check-ins and Medicare telehealth .

Is my test, item, or service covered?

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Prince Harry undeterred by security concerns, confirms UK visit for Invictus Games

Former Royal security expert assures Harry's protection

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Prince Harry is determined to visit the UK next month for the Invictus Games celebrations, despite concerns about his security. There were speculations that he might opt for a virtual presence due to security issues, but a former royal security expert has dismissed this idea.

Former head of royal protection Dai Davies spoke exclusively to the Mirror, assuring that Prince Harry will not be deterred by security concerns. Davies highlighted the expertise of Harry's Chief of Protection, who is an ex-Sergeant in royalty protection and highly trained. He also emphasized the support structure that Harry would receive, even if he doesn't have armed protection.

Davies mentioned the role of the RAVEC (Royalty and VIP Executive Committee) in ensuring Harry's protection during his visit. He stated, "The RAVEC will still ensure the Duke is protected and won't leave him exposed," highlighting the measures in place to safeguard Harry during his time in the UK. He also pointed out that Harry has been protected while visiting the UK since 2020, emphasizing the ongoing commitment to his security.

Regarding the intelligence and decision-making process behind Harry's protection, Davies expressed confidence in the thoroughness of the assessments. He reassured, "They have stood by it, the government has stood by it, and the Home Office." He emphasized the non-personal nature of the security measures, stressing the professional evaluation of necessity and intelligence warranting the protection.

Harry's UK visit backed by Government and Home Office

In light of these assurances, it is clear that Prince Harry is resolute in his decision to attend the Invictus Games celebrations in person. Despite the previous concerns and speculations, his determination to be present for the milestone event remains unwavering.

This reaffirms Prince Harry's commitment to the Invictus Games and his desire to personally participate in the celebrations. His dedication to honoring and supporting the achievements of wounded, injured, and sick service personnel and veterans through the Invictus Games is evident in his decision to overcome any potential obstacles to his visit.

In conclusion, Prince Harry's upcoming visit to the UK for the Invictus Games celebration is a testament to his unwavering support for the event and its participants. Despite security concerns, his determination to be present underscores his dedication to this meaningful cause.

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A History of Moscow in 13 Dishes

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The life and music of Amy Winehouse, through the journey of adolescence to adulthood and the creation of one of the best-selling albums of our time. The life and music of Amy Winehouse, through the journey of adolescence to adulthood and the creation of one of the best-selling albums of our time. The life and music of Amy Winehouse, through the journey of adolescence to adulthood and the creation of one of the best-selling albums of our time.

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Russia-related Designations and Designations Updates; Issuance of Russia-related General Licenses

The Department of the Treasury's Office of Foreign Assets Control (OFAC) is issuing Russia-related General License 79 , "Authorizing the Wind Down of Transactions Involving Certain Entities Blocked on December 12, 2023," and Russia-related General License 80 , "Authorizing Certain Transactions Related to Debt or Equity of, or Derivative Contracts Involving, Highland Gold Mining Limited."

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• Digital Health Challenge winners visit eHealth NSW office

26 April 2024

eHealth NSW hosted 10 students from Loreto Normanhurst School for a special event at the Chatswood office on 11 March 2024. These students were winners and finalists of the Digital Health Challenge, presented by eHealth NSW in collaboration with the Association of Independent Schools (AIS) NSW late last year.

Students had the opportunity to pitch their ideas to the eHealth NSW Executive Management Team (EMT), demonstrating their application of digital health solutions.

The challenge, held as part of the Partnering with Schools program, was designed to inspire creative problem-solving among students, while introducing them to new health and digital literacy concepts.

Ideas pitched included a leave support app for staff on maternity leave (inTouch) and a platform that translates resources into multiple languages (ALBUT), with students impressing the EMT with their research and presentation skills.

The winning idea was Digital Health Drive, an internet-enabled van that visits rural areas to support people with internet access so they can learn and navigate digital health solutions.

Tenielle Davies, a teacher at Loreto Normanhurst said the challenge sparked the curiosity of students to further engage with NSW Health resources that many did not know existed.

“Students had the opportunity to use innovative problem solving as well as gain a greater perspective of career opportunities in health,” she said.

During their visit to our office, students had the opportunity to learn more about eHealth NSW, its staff and programs, like Telestoke and the organisation’s role in keeping the health system safe from cyber-attacks.

eHealth NSW has been partnering with the Association of Independent Schools (AIS) NSW for over two years to encourage students to engage with STEM (Science, Technology, Engineering and Mathematics) learning and introduce them to a possible future career in digital health.

The Partnering with Schools program provides a platform for eHealth NSW to connect with students, schools and their broader communities to understand their health system needs to inform the planning, design and delivery of digital solutions.

The program is an opportunity to give back to the community. It’s a way for us to share our knowledge of the health system and digital health technologies. This can contribute to building greater health literacy in the community.

The program also showcases how digital technologies can impact individual health and wellbeing as well as health information now and into the future.

If you want to learn more about the program, please email the eHealth NSW Consumer Engagement team .

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Getting clear on the new coding rules can help you eliminate bloated documentation and improve reimbursement to reflect the value of your visits.

THOMAS WEIDA, MD, FAAFP, AND JANE WEIDA, MD, FAAFP

Fam Pract Manag. 2022;29(1):26-31

Author disclosures: no relevant financial relationships.

In 2021, significant changes were adopted for the documentation guidelines for outpatient evaluation and management (E/M) visit codes. Most notably, medical decision making or time became primary drivers of visit level selection, rather than the number of history and physical exam bullets.

In this article, we review the context for these changes, describe them briefly, and offer a quick reference tool to help physicians apply the new rules in practice.

The revisions to the E/M outpatient visit codes reduced administrative burden by eliminating bullet points for the history and physical exam elements.

Code level selection is now simplified — based on either medical decision making or total time.

The authors' one-page coding reference tool can help simplify the new rules.

HOW WE GOT HERE

In the 2019 Medicare physician fee schedule final rule, released in November 2018, the Centers for Medicare & Medicaid Services (CMS) adopted revisions to the outpatient E/M codes in order to reduce administrative burden. (See https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year .) Originally scheduled for implementation in 2021, these changes would have combined visit levels 2–4 into a blended payment rate (e.g., one rate for 99202-99204 and one rate for 99212-99214), among other changes.

In response, the American Medical Association (AMA) convened a joint CPT Editorial Board and Relative Value Scale Update Committee (RUC) workgroup to build on the changes and propose some alternatives. The workgroup's goals were to decrease administrative burden, payer audits, and unnecessary medical record documentation while ensuring that payment of E/M services is resource-based.

The workgroup approved significant revisions to the outpatient office visit E/M codes. Code 99201 was deleted. The history and/or physical examination and the counting of bullets were eliminated as components for code selection (although history and/or physical examination documentation should still be performed as medically appropriate). Medical decision making (MDM) or time could be used for code level selection. Changes were made to the code descriptors for 99202-99205 and 99211-99215, the definition of medical decision making, and the calculation of time, and a shorter prolonged services add-on code was created. CMS adopted these new E/M coding guidelines. As a result of the changes to medical decision making and time-based coding, the RUC revised the 2021 relative value units (RVUs) for office visit E/M codes. Most of the values increased, yielding an overall increase of more than 10%.

CODING BASED ON MEDICAL DECISION MAKING

For outpatient E/M coding, medical decision making now has three components:

Number and complexity of problems addressed at the encounter,

Amount and/or complexity of data to be reviewed and analyzed,

Risk of complications and/or morbidity or mortality of patient management.

There are four levels of decision making for each of these components: straightforward, low complexity, moderate complexity, and high complexity.

To determine the level of code for a visit, two of the three components must meet or exceed that level of coding. ( See the table .) For example, if the patient has multiple problems addressed at the encounter, but the data is limited and the risk of complications is low, then the level of medical decision making would be low. New patient codes 99202-99205 and established patient codes 99212-99215 use the same components and levels of decision making for code selection.

Determining medical decision making usually starts with identifying the number and complexity of problems addressed and then determining the data or risk components that support that medical decision making. If a second component does not meet or exceed the problem component, then a lower level of decision making is appropriate. The set of tables below illustrate the essential concepts of these code levels. Each level has specific criteria for each component.

Straightforward medical decision making: Codes 99202 and 99212 include one self-limited or minor problem with minimal or no data and minimal risk.

An example of a 99202 or 99212 is an otherwise healthy patient with cough and congestion due to the common cold.

Low complexity medical decision making: Codes 99203 and 99213 include two or more self-limited or minor problems, one stable chronic illness, or one acute uncomplicated illness or injury.

The data component requires one of two categories to establish the level. Category 1 data requires at least two items in any combination of the following: each unique source's prior external notes reviewed, each unique test result reviewed, or each unique test ordered. Tests include imaging, laboratory, psychometric, or physiologic data. A clinical lab panel, such as a complete blood count, is a single test. Of note, if a test is ordered, the review of that test is included with the ordering, even if the review is done at a subsequent visit. Tests ordered outside of an encounter may be counted in the encounter in which they are analyzed. Category 2 data includes significant history given by an independent historian. Parents giving the history for their child is a typical example.

The risk component is low. There is low risk of morbidity from additional diagnostic testing or treatment.

An example of a 99203 or 99213 is a sinus infection treated with an antibiotic. Although the prescription makes the risk component moderate, the one acute uncomplicated illness is a low-complexity problem, and there are no data points.

Moderate complexity medical decision making: Codes 99204 and 99214 include two or more stable chronic illnesses, one or more chronic illnesses with exacerbation, progression, or side effects of treatment, one undiagnosed new problem with uncertain prognosis, one acute illness with systemic symptoms, or one acute complicated injury. A patient who is not at a treatment goal, such as a patient with poorly controlled diabetes, is not stable. Systemic general symptoms such as fever or fatigue in a minor illness (e.g., a cold with fever) do not raise the complexity to moderate. More appropriate would be fever with pyelonephritis, pneumonitis, or colitis.

The data component requires one of three categories to establish the level. Category 1 data requires at least three items in any combination of the following: each unique source's prior external notes reviewed, each unique test result reviewed, each unique test ordered, or independent historian involvement. Physicians cannot count tests that they or someone of the same specialty and same group practice are interpreting and reporting separately (e.g., electrocardiogram, X-ray, or spirometry). Category 2 data includes the independent interpretation of a test performed by another physician/other qualified health care professional (QHP) (not separately reported). For instance, if a chest X-ray was ordered and the ordering clinician included the interpretation in the visit documentation, this would qualify for data point Category 2. However, if the ordering clinician bills separately for the interpretation of the X-ray, then that cannot be used as an element in this category and would be an element for Category 1. Category 3 data includes discussion of management or test interpretation with an external physician/QHP (not separately reported).

The risk component may include prescription drug management, a decision for minor surgery with patient or procedure risk factors, a decision for elective major surgery without patient or procedure risk factors, or social determinants of health (SDOH) that significantly limit diagnostic or treatment options, such as food or housing insecurity. For prescription drug management, renewing pre-existing chronic medications would qualify. Documentation that the physician is managing the patient for the condition for which the medications are being prescribed would help establish validity in the use of this criterion for MDM.

An example of a 99204 or 99214 is a patient being seen for follow-up of hypertension and diabetes, which are well-controlled. An example using SDOH would be a patient with chronic knee pain and a positive anterior drawer test who needs imaging of the knee but cannot afford this care. Documenting that the patient cannot afford to obtain an MRI of the knee at this time, which significantly limits your ability to confirm the diagnosis and recommend treatment, adds to the risk component.

High complexity medical decision making: Codes 99205 and 99215 include one or more chronic illnesses with a severe exacerbation, progression, or side effects of treatment, or one acute or chronic illness or injury that poses a threat to life or bodily function.

The data component requires two of three categories to establish the level. These data categories are the same as those for 99204 and 99214, and they follow the same rules.

The risk component may include drug therapy requiring intensive monitoring for toxicity. Decisions regarding elective major surgery with patient or procedure risk, emergency major surgery, hospitalization, or “do not resuscitate” orders are also high risk. Intensive prescription drug monitoring is typically supported by a laboratory test, physiologic test, or imaging, and is done to evaluate for complications of the treatment. It may be short-term or long-term. Long-term monitoring is at least quarterly. An example would be monitoring for cytopenia during antineoplastic therapy. Monitoring the therapeutic effect of a treatment, such as glucose monitoring during insulin therapy, is not considered intensive prescription drug monitoring.

An example of a 99205 or 99215 is a patient with severe exacerbation of chronic heart failure who is admitted to the hospital.

CODING OUTPATIENT E/M VISITS

Time-based coding.

An alternative method to determine the appropriate visit level is time-based coding. A major change is that total time now includes both face-to-face and non-face-to-face services personally performed by the physician/QHP on the day of the visit. Additionally, time-based coding is no longer restricted to counseling services. Instead, it includes the following:

Preparing to see the patient (e.g., reviewing external test results),

Obtaining and/or reviewing separately obtained history,

Performing a medically appropriate examination and/or evaluation,

Counseling and educating the patient, family, or caregiver,

Ordering medications, tests, or procedures,

Referring and communicating with other health care professionals (when not separately reported),

Documenting clinical information in the electronic or other health record,

Independently interpreting results (not separately reported with a CPT code) and communicating results to the patient, family, or caregiver.

Care coordination (not separately reported with a CPT code).

Time spent by clinical staff cannot count toward total time. However, time spent by another physician/QHP (not a resident physician) in the same group can be included. If a nurse practitioner performs the initial intake and the physician provides the assessment and plan, both of those times can be counted, although only one person's time can be counted while they are discussing the case with each other. The visit should be billed under the clinician who provided the substantive portion (more than half) of the time, although both clinicians need to be identified in the medical record. Time spent must be documented in the note. It is advisable to specifically document the time spent and the activities performed both face-to-face and non-face-to-face.

The amount of total time required for each level of coding changed under the new time-based coding guidelines. (See the “Total time ” table.)

PROLONGED VISIT CODES

When time on the date of service extends beyond the times for codes 99205 or 99215, prolonged visit codes can be used. The AMA CPT committee developed code 99417 for prolonged visits, and Medicare developed code G2212. These are added in 15-minute increments in addition to codes 99205 or 99215. Code G2212 can be added once the maximum time for 99205 or 99215 has been surpassed by a full 15 minutes, whereas code 99417 can be added once the minimum time for 99205 or 99215 has been surpassed by a full 15 minutes. Less than 15 minutes is not reportable. Multiple units can be reported. Prolonged visit codes cannot be used with the shorter E/M levels, i.e., 99202-99204 and 99212-99214. (See “Prolonged services ” tables.) Clinicians should consult with individual payers to determine which code to use — G2212 or 99417.

SIMPLIFIED CODING AND DOCUMENTATION

The revisions to the outpatient E/M visit codes reduced administrative burden by eliminating bullet points for the history and physical exam elements. Only medically appropriate documentation is required. Code level selection is simplified — based on either medical decision making or total time. By applying these changes, primary care clinicians can eliminate bloated documentation and improve reimbursement reflecting the value of the visit.

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Prosecutors seek to ask Trump about civil fraud, E. Jean Carroll cases and more if he testifies in hush money case

Prosecutors from the Manhattan district attorney's office said in a court filing Wednesday that they plan to ask Donald Trump about the costly verdicts and findings of wrongdoing in his numerous civil cases if the former president decides to testify in the criminal case — though the permissibility of that line of questioning remains to be seen.

The prosecutors said they intend to ask Trump about the judgment in New York Attorney General Letitia James' civil fraud suit against him and his company, as well as a pair of verdicts in lawsuits brought by writer E. Jean Carroll. The judgments in the three cases total almost $ 550 million and include findings that Trump committed fraud in the AG's case and that he is liable for sexual abuse and defamation in the Carroll case.

District Attorney Alvin Bragg's office also plans to mention findings by the judge in the civil fraud case that Trump violated a gag order and " testified untruthfully under oath" during the trial.

Prosecutors said they want to be able to bring up those findings — which Trum p is a p p ealing — "to impeach the credibility of the defendant" if he takes the witness stand.

Trump said last week he "a bsolutely " plans to testify but is under no obligation to do so.

If he does take the stand, prosecutors would also like to ask him about the verdict in the DA's successful criminal tax fraud prosecution of the Trump Organization and a settlement his Trump Foundation struck with the AG's office in 2019. A federal judge  ordered Trump to pay $2 million in damages  in that case after the foundation admitted in a settlement that Trump had misused foundation funds to help his 2016 presidential campaign, settle personal legal disputes and buy portraits of himself.

They also want Judge Juan Merchan to allow them to ask about a Trump lawsuit against Hillary Clinton and others that resulted in Trump and one of his lawyers being sanctioned and ordered to pay $937,989 in fees for filing a frivolous, bad-faith lawsuit. The judge in that case handed down the penalty after having found that "Mr. Trump is a prolific and sophisticated litigant who is repeatedly using the courts to seek revenge on political adversaries. He is the mastermind of strategic abuse of the judicial process, and he cannot be seen as a litigant blindly following the advice of a lawyer. He knew full well the impact of his actions."

Prosecutors made the disclosure ahead of a type of hearing called a Sandoval hearing, which is tentatively scheduled for Friday. Sandoval hearings are designed to allow defendants to make informed decisions about whether to testify by providing pretrial determinations of the permissible scope of cross-examination by prosecutors.

Trump's attorneys told the judge in a l etter last month that they will argue the DA's office should be barred "from asking about these items."

The trial, the first criminal trial against a former president, was off Wednesday, but it resumes with jury selection Thursday. Trump has pleaded  not guilty  to 34 counts of falsifying business records related to a hush money payment to a porn star during the closing days of the 2016 presidential election. He faces up to four years in prison if he is convicted.

Adam Reiss is a reporter and producer for NBC and MSNBC.

Dareh Gregorian is a politics reporter for NBC News.