Current Billing Guidelines for E/M and Diagnostic Testing Codes

Office/Outpatient E/M Codes: Time and MDM Requirements

• The American Medical Association recommends that for all office visit codes, billing can be based on either total time spent on the date of encounter or medical decision-making complexity, choosing whichever yields the appropriate level of service 1
• For new patient visits, the Centers for Medicare and Medicaid Services guidelines state that 99202 requires 15-29 minutes total time or straightforward MDM, 99203 requires 30-44 minutes total time or low complexity MDM, 99204 requires 45-59 minutes total time or moderate complexity MDM, and 99205 requires 60-74 minutes total time or high complexity MDM 1
• For established patient visits, the Centers for Medicare and Medicaid Services guidelines state that 99212 requires 10-19 minutes total time or straightforward MDM, 99213 requires 20-29 minutes total time or low complexity MDM, 99214 requires 30-39 minutes total time or moderate complexity MDM, and 99215 requires 40-54 minutes total time or high complexity MDM 1
• The American Academy of Sleep Medicine states that CPT 99293 is not a standard outpatient code and represents critical care services for each additional 30 minutes beyond the first 74 minutes 2

MDM Complexity Determination

• The American Medical Association recommends that to qualify for a specific MDM level, 2 out of 3 elements must be met: number/complexity of problems addressed, amount/complexity of data reviewed, and risk of complications 1
• The Centers for Medicare and Medicaid Services guidelines state that problems must be actively addressed during the encounter, not merely listed in the chart, and that an undiagnosed new problem with uncertain prognosis qualifies as moderate complexity 1

Billing Strategy

• The American Gastroenterological Association recommends calculating both time-based and MDM-based code levels for each encounter, then billing whichever is supported by documentation and yields the appropriate level 3, 4
• The American Medical Association states that time-based billing requires documenting total face-to-face time with the patient 1

Diagnostic Testing Procedure Codes

• The American Academy of Pediatrics recommends using CPT 96110 for developmental screening and 96111 for extended developmental testing by the physician 5
• The American Medical Association states that 96110 does not include physician work, while 96111 includes physician evaluation, interpretation, and report generation 5

Common Pitfalls to Avoid

• The Centers for Medicare and Medicaid Services guidelines state that outdated 2013 time thresholds should not be used, as the 2021 guidelines significantly changed time requirements 1
• The American Medical Association recommends not billing standard office visit codes for routine wellness care when dedicated preventive care codes exist 5
• The American Gastroenterological Association states that telemedicine codes should not be used without appropriate Place of Service codes and telehealth modifiers 3, 4

E&M Code Assessment for Patient Visits with Moderate Complexity

Documentation Requirements

• The American Academy of Pediatrics, as reported in Pediatrics, recommends ensuring documentation includes clear statements of problems addressed, risk assessment, total time if using time-based coding, and medical decision-making rationale to support 99214 coding 6

Medical Decision-Making Complexity Analysis

• The American Medical Association defines "undiagnosed new problem with uncertain prognosis" as moderate complexity, which is relevant for patients presenting with multiple undiagnosed problems, such as dehydration, electrolyte abnormalities, cardiac issues, infection, malignancy, or other systemic illness, and this definition supports the use of 99214 coding 6

Medical Decision-Making for Established Patient Visits

Moderate Complexity Criteria

• The American Academy of Pediatrics recommends that a review of previous medical records, coordination of care, and performing medically appropriate evaluations are essential components of moderate complexity medical decision-making, which supports the use of CPT code 99214 for established patient visits 7
• The Academy suggests that coordinating multiple referrals, referring and communicating with therapy providers, and care coordination for multiple therapeutic interventions demonstrate moderate complexity and support the use of CPT code 99214 7
• The presence of multiple chronic conditions, such as autism spectrum disorder with associated feeding disorder, and the need for coordination of care with multiple specialists, contributes to moderate complexity medical decision-making, as outlined by the American Academy of Pediatrics 7

Time-Based Coding Considerations

• The American Medical Association guidelines indicate that 99214 can be billed based on either total time or medical decision-making complexity, whichever is supported by documentation, with a time threshold of 30-39 minutes for time-based coding 7

Assessment of Medical Billing Template Accuracy

Telemedicine and Billing Guidelines

• The American Medical Association and the Centers for Medicare and Medicaid Services recommend using 99202-99215 with Modifier 95 for audiovisual or Modifier 93 for audio-only telehealth services, which is compliant with current CMS telehealth billing requirements 8
• The American Telemedicine Association standards require documentation of patient consent, method, location, and participants for telehealth services 8
• The use of "[PATIENT]" and "[PROVIDER]" placeholders is non-standard for clinical documentation, and actual documentation should use proper identifiers compliant with HIPAA requirements 9

Medical Coding and Complexity

• The American Medical Association requires meeting 2 of 3 MDM elements (Problems, Data, Risk) at a given level, and independent historian use contributes to the Data category but does not automatically elevate MDM to Low Complexity 8
• The correct standard for Low Complexity Data is meeting Category 1 (tests, documents, or independent historian), and Moderate Complexity Data requires meeting 1 of 3 lists (independent interpretation, discussion with external provider, or appropriate source) 8

State-Specific Billing Rules and Modifier Requirements

• State Medicaid programs and commercial payers often have variations in modifier requirements beyond 95/93, prior authorization requirements for telehealth, reimbursement parity between in-person and telehealth visits, and audio-only visit coverage 8
• The American Medical Association explicitly permits billing based on either total time or MDM complexity, whichever is supported by documentation, and the "Compare Select the method (MDM vs Time) that yields the HIGHER code" instruction is correct and compliant 8

Prescription and Order Documentation

• The requirement to use ICD-10 codes for all diagnoses aligns with current coding standards, and the inclusion of AI scribe disclosure is appropriate but should specify whether this disclosure affects billing 9
• The American College of Cardiology recommends using ICD-10 codes for all diagnoses, and the use of ICD-10 codes is compliant with current coding standards 9

Billing Guidelines for New Patient Establishing Care

Coding and Documentation

• When addressing both preventive care and active medical problems, the American Academy of Pediatrics recommends billing both the preventive code and an appropriate E/M code with modifier -25 10