Helpful information for your practice- Not on Quizzes
Billing and Coding: In the Outpatient Setting
Reference: Baldridge, K. (2022). Billing & coding: In the outpatient clinical setting. Advanced
Practice Education Associates.
Refer to this site for more specific information regarding Billing and Coding:
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/
downloads/eval-mgmt-serv-guide-icn006764.pdf
*Determining the appropriate level of E/M (evaluation and management) service:
Is patient new or established > Bill according to medical decision making or time? > Choose the
method that provides the highest level that can be documented > Document a medically
appropriate history and or examination
Step 1: New or Established Patient:
● New Patient: a patient who has never received professional face-to-face services from
you and/or anyone in your group practice in the exact same specialty; a patient who has
not received professional services from you and/or anyone in your group practice in the
previous 3 years
● Established Patient: a patient who has received professional face-to-face services from
you and or anyone in your group practice in the same exact specialty in the previous
three years
Step 2: Determine of E/M Code will be based on Medical Decision Making (MDM) or Time:
● Medical decision making refers to the complexity of establishing a diagnosis and/or
selecting management option
● There are four levels of medical decision making: straightforward, low, moderate, high
● The three elements to help determine the level of medical decision making our: 1.
number and complexity of problems addressed, 2. amount and or complexity of data
reviewed and analyzed, and 3. risk of complications and/or morbidity or mortality of
patient management
● Time-based E/M coding denotes the total amount of time spent on non-face-to-face and
face-to-face activities provided by the provider on the calendar date of the patient
encounter
Summary of E/M codes comparing time and MDM levels:
New Patient:
● 99202, straightforward MDM, 15-29
minutes
● 99203, low MDM, 30-44 minutes
● 99204, moderate MDM, 45-59 minutes
● 99205, high MDM, 60-74 minutes
, Est. Patient:
● 99211- service provided by ancillary office personnel
● 99212, straightforward MDM, 10-19 minutes
● 99213, low MDM, 20-29 minutes
● 99214, moderate MDM, 30-39 minutes
● 99215, high MDM, 40–54 minutes
E/M coding according to medical decision making:
Three elements of MDM:
● Number and complexity of problems addressed
● Amount and/or complexity of data reviewed and analyzed
● Risk of complications and/or morbidity or mortality of patient management
***The level of complexity and thus the E/M visit code is determined based on meeting or
exceeding two of the three elements of MDM.
First element of MDM: number and complexity of problems addressed
*In determining the number of possible diagnoses and or number of management options
consider:
● The number and types of problems addressed during the encounter
● The complexity establishing a diagnosis
● The extensiveness of the evaluation required to reach a diagnosis is considered in
determining complexity, not necessarily the final diagnosis
● Symptoms may cluster around a specific diagnosis, and each symptom is not
necessarily a unique condition
● Comorbidities/underlying diseases are not considered unless specifically addressed, and
their presence increases the amount and or complexity of data to be reviewed and
analyzed or the risk of complications and or morbidity or mortality
● Multiple problems on the lower severity may, together, create higher complexity
● Documentation must reflect that problems were sufficiently evaluated and or treated at
the encounter
● Simple notation of another health professional managing a problem without additional
assessment or care coordination does not qualify
*Refer to this reference for more specific information:
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/
downloads/eval-mgmt-serv-guide-icn006764.pdf
Second element of MDM: the amount and/or complexity of data to be reviewed and analyzed
Data are divided into three categories:
● Test, documents, orders, or independent historian
● Independent interpretation of tests
● Discussion of management or test interpretation with external physician or other
Qualified healthcare provider (QHP) or appropriate source
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/
downloads/eval-mgmt-serv-guide-icn006764.pdf
Billing and Coding: In the Outpatient Setting
Reference: Baldridge, K. (2022). Billing & coding: In the outpatient clinical setting. Advanced
Practice Education Associates.
Refer to this site for more specific information regarding Billing and Coding:
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/
downloads/eval-mgmt-serv-guide-icn006764.pdf
*Determining the appropriate level of E/M (evaluation and management) service:
Is patient new or established > Bill according to medical decision making or time? > Choose the
method that provides the highest level that can be documented > Document a medically
appropriate history and or examination
Step 1: New or Established Patient:
● New Patient: a patient who has never received professional face-to-face services from
you and/or anyone in your group practice in the exact same specialty; a patient who has
not received professional services from you and/or anyone in your group practice in the
previous 3 years
● Established Patient: a patient who has received professional face-to-face services from
you and or anyone in your group practice in the same exact specialty in the previous
three years
Step 2: Determine of E/M Code will be based on Medical Decision Making (MDM) or Time:
● Medical decision making refers to the complexity of establishing a diagnosis and/or
selecting management option
● There are four levels of medical decision making: straightforward, low, moderate, high
● The three elements to help determine the level of medical decision making our: 1.
number and complexity of problems addressed, 2. amount and or complexity of data
reviewed and analyzed, and 3. risk of complications and/or morbidity or mortality of
patient management
● Time-based E/M coding denotes the total amount of time spent on non-face-to-face and
face-to-face activities provided by the provider on the calendar date of the patient
encounter
Summary of E/M codes comparing time and MDM levels:
New Patient:
● 99202, straightforward MDM, 15-29
minutes
● 99203, low MDM, 30-44 minutes
● 99204, moderate MDM, 45-59 minutes
● 99205, high MDM, 60-74 minutes
, Est. Patient:
● 99211- service provided by ancillary office personnel
● 99212, straightforward MDM, 10-19 minutes
● 99213, low MDM, 20-29 minutes
● 99214, moderate MDM, 30-39 minutes
● 99215, high MDM, 40–54 minutes
E/M coding according to medical decision making:
Three elements of MDM:
● Number and complexity of problems addressed
● Amount and/or complexity of data reviewed and analyzed
● Risk of complications and/or morbidity or mortality of patient management
***The level of complexity and thus the E/M visit code is determined based on meeting or
exceeding two of the three elements of MDM.
First element of MDM: number and complexity of problems addressed
*In determining the number of possible diagnoses and or number of management options
consider:
● The number and types of problems addressed during the encounter
● The complexity establishing a diagnosis
● The extensiveness of the evaluation required to reach a diagnosis is considered in
determining complexity, not necessarily the final diagnosis
● Symptoms may cluster around a specific diagnosis, and each symptom is not
necessarily a unique condition
● Comorbidities/underlying diseases are not considered unless specifically addressed, and
their presence increases the amount and or complexity of data to be reviewed and
analyzed or the risk of complications and or morbidity or mortality
● Multiple problems on the lower severity may, together, create higher complexity
● Documentation must reflect that problems were sufficiently evaluated and or treated at
the encounter
● Simple notation of another health professional managing a problem without additional
assessment or care coordination does not qualify
*Refer to this reference for more specific information:
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/
downloads/eval-mgmt-serv-guide-icn006764.pdf
Second element of MDM: the amount and/or complexity of data to be reviewed and analyzed
Data are divided into three categories:
● Test, documents, orders, or independent historian
● Independent interpretation of tests
● Discussion of management or test interpretation with external physician or other
Qualified healthcare provider (QHP) or appropriate source
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/
downloads/eval-mgmt-serv-guide-icn006764.pdf
