Urgent Care E/M

Physicians/QHPs that provide care in an Urgent Care Center or Fast Track report their services with the Office or Other Outpatient E/M codes 99202-99215.

AMA and CMS approved new CPT E/M guidelines for the Office or Other Outpatient E/M codes 99202-99215, originally effective January 2021 and updated for January 2023.

The differences between the 2021/2023 CPT E/M Guidelines for the office visit codes and 1995 CMS E/M guidelines include:

• They eliminate history and physical exam as elements for code selection.
  • The revised code descriptors state providers should perform a “medically appropriate history and/or examination.” However, these elements are not used to determine the appropriate code level.
• Allowing physicians/QHPs to choose E/M codes based on Medical Decision Making or Total Time.
• Revisions to the rules for using Time to assign an E/M code.
• Modifications to the criteria for determining Medical Decision Making (MDM).

When reporting the Office or Other Outpatient E/M codes 99202-99215, the documentation should include a medically appropriate history and/or physical examination.

The nature and extent of the history and/or physical examination are determined by the treating physician/QHP. But the extent of history and physical exam documented is not used to assign the level of service when reporting the Office or Other Outpatient E/M codes 99202-99215.

• There are minor changes to the three current MDM sub-components, but there have been extensive edits to the process of “scoring” MDM elements for code selection.
• The current CMS Table of Risk and Contractor audit tools were used as a basis for designing the revised required elements for MDM.
• Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
• Defined important terms, such as “Independent historian,” “other appropriate source,” etc.

Three elements define medical decision making in the office and other outpatient services code set:

• The number and complexity of problem(s) that are addressed during the encounter.
• The amount and/or complexity of data to be reviewed and analyzed.
• The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit.

When assigning an E/M by MDM, the documentation must satisfy the requirement of at least two columns to report a level of service.

See the 2023 E/M Documentation Guidelines for a more detailed discussion of Number and Complexity of Problem(s) Addressed.  

See the 2023 E/M Documentation Guidelines for a more detailed discussion of Amount and/or Complexity of Data Reviewed.

See the 2023 E/M Documentation Guidelines for a more detailed discussion of Risk of Complications and/or Morbidity or Mortality.

As of 2023:

• Physicians/QHPs must document their total time and satisfy the times specified in the code descriptors to report the E/M code.
• Time alone may be used to select the appropriate code level for the office E/M services codes regardless of counseling and/or coordination of care dominating the service.
• Time included is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician on the day of the encounter (includes time in activities that require the physician and does not include time in activities customarily performed by clinical staff).

Calculating the physician’s professional time includes the following activities when performed:

• preparing to see the patient (e.g., review of tests)
• obtaining and/or reviewing separately obtained history
• performing a medically appropriate examination and/or evaluation
• counseling and educating the patient/family/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) and communicating results to the patient/family/caregiver.
• care coordination (not separately reported)

Time spent performing separately billed services is not counted toward the time used to select the E/M code.

New Patient:

• 99201             Deleted as of 2021.
• 99202             15 minutes
• 99203             30 minutes
• 99204             45 minutes
• 99205             60 minutes

A new patient has not received any professional services from the physician/QHP or another physician/QHP of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.

Established Patient:

• 99211 Nurse visit, may not require the presence of a physician/QHP.
• 99212             10 minutes
• 99213             20 minutes
• 99214             30 minutes
• 99215             40 minutes

An established patient has received any professional services from the physician/QHP or another physician/QHP of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.

Prolonged services can be reported when the physician’s total time during an office E/M service exceeds the maximum time associated with 99205 or 99215.

For non-Medicare patients, Code 99417 (Prolonged office/outpatient E/M services with or without direct patient contact) is only used when time alone is the basis for selecting the E/M code and only after the total time of the highest-level service (i.e., 99205 or 99215) has been exceeded.

New Patient

• 75-89 minutes 99205 X 1 and 99417 X 1
• 90-104 minutes 99205 X 1 and 99417 X 2
• 105 or more             99205 X 1 and 99417 X 3 or more for each additional 15 minutes.

Established Patient

• 55-69 minutes 99215 X 1 and 99417 X 1
• 70-84 minutes 99215 X 1 and 99417 X 2
• 85 or more             99215 X 1 and 99417 X 3 or more for each additional 15

For Medicare patients, CMS policy instructs providers not to report prolonged office/outpatient E/M visit time using CPT code 99417.  CMS instructions are to report G2212 when prolonged service has been provided.

• G2212 - (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact)

CMS provides the following table with reporting examples:

New Patient

• 89-103 minutes 99205 x 1 and G2212 x 1
• 104-118 minutes 99205 x 1 and G2212 x 2
• 119 or more 99205 X 1 and G2212 X 3 or more for each additional 15 minutes.

Established Patient

• 69-83 minutes 99215 x 1 and G2212 x 1
• 84- 98 minutes 99215 x 1 and G2212 x 2
• 99 or more             99215 x 1 and G2212 x 3 or more for each additional 15 minutes.

On July 1, 2022, the AMA released additional revisions to the rest of the E/M code sections, including the ED E/M codes.  The 2022 revisions will provide continuity across all the E/M sections.

The revised E/M codes, descriptions, and guidelines will apply to all E/M codes on January 1st, 2023.

See the 2023 E/M FAQ for more information.

Yes, observation services will now use the MDM guidelines detailed above, or observation E/M codes can be assigned based on the physician’s total time on the encounter date.

However, the  Initial Observation Care codes 99218, 99219, and 99220, Subsequent Observation Care codes 99224, 99225, 99226, and Observation Discharge code 99217 have all been deleted for 2023. 

The inpatient E/M codes 99221-99223, and 99231-99239, have been revised to Hospital Inpatient and Observation Care Services.

See the Physician Observation FAQ for more information.

They can be found in the Evaluation and Management (E/M) Services Guidelines section of the 2023 CPT Manual. They can also be downloaded from the AMA website with this link https://www.ama-assn.org/system/files/2023-e-mdescriptors-guidelines.pdf