Evaluation and Management Coding Guidelines

Time Thresholds

The American Academy of Pediatrics recommends that established patients require 30-39 minutes for 99214, not 25 minutes 1, 2
The American Academy of Pediatrics recommends that new patients require 45-59 minutes for 99204, not 45 minutes 1, 2
The American Academy of Pediatrics recommends that established patients require 40-54 minutes for 99215, not 40 minutes 1, 2
The American Academy of Pediatrics recommends that new patients require 60-74 minutes for 99205, not 60 minutes 1, 2

The American Medical Association states that problems must be "addressed" during the encounter, not just listed 3
The American Medical Association states that "undiagnosed new problem with uncertain prognosis" is a moderate complexity problem 3
The American Medical Association requires "extensive" data for high complexity MDM, which means 3 points from Category 1 OR 2 points from Category 2 3

The American Medical Association states that only 2 of 3 MDM elements (Problems, Data, Risk) need to be met at a given level to qualify for that level 3
The American Medical Association states that if 2 out of 3 elements meet "moderate complexity," the overall MDM is moderate 3

The American Medical Association recommends calculating both MDM-based and time-based codes, then billing based on whichever is supported by documentation 3
The American Medical Association states that billing should be based on what was actually done and documented, not on maximizing reimbursement 3

The American Academy of Pediatrics recommends a time threshold of 15-29 minutes for 99202 1, 2
The American Academy of Pediatrics recommends a time threshold of 30-44 minutes for 99203 1, 2
The American Academy of Pediatrics recommends a time threshold of 45-59 minutes for 99204 1, 2
The American Academy of Pediatrics recommends a time threshold of 60-74 minutes for 99205 1, 2
The American Academy of Pediatrics recommends a time threshold of 10-19 minutes for 99212 1, 2
The American Academy of Pediatrics recommends a time threshold of 20-29 minutes for 99213 1, 2
The American Academy of Pediatrics recommends a time threshold of 30-39 minutes for 99214 1, 2
The American Academy of Pediatrics recommends a time threshold of 40-54 minutes for 99215 1, 2

The American Academy of Pediatrics warns against using outdated 2013 time thresholds instead of current 2021+ guidelines 1, 2
The American Medical Association warns against failing to document the "2 of 3" MDM rule explicitly 3