Guidelines for E/M Reporting

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Practice Management

Documentation requirements for E/M visits will also be revised to include two separate sets of reporting guidelines:

One set for reporting office/outpatient E/M visits
One set for reporting all other E/M visits that are not furnished in the office/outpatient setting

The table below highlights several major differences in reporting guidelines for E/M visits that went into effect on January 1, 2021

Question	Office/Outpatient E/M Visits (99202-99205, 99211-99215, 99417, G2212)	All Other E/M Visits (e.g., consultation, inpatient, observation, nursing home, emergency department visits)
Which reporting guidelines apply to E/M services?	New: Code selection is based on medical decision making OR total time on the date of encounter.	No change: The 1995 and 1997 E/M documentation guidelines continue to apply to all other E/M services not furnished in the office or other outpatient setting.
Are history and physical examination (H&P) required elements?聽	New: History and/or examination is required only as medically appropriate for all levels of both new and established patient codes.	No change: The four categories of H&P (problem focused, expanded problem focused, detailed, and comprehensive) are still applicable in E/M code selection.聽
When using time for reporting, how should it be used for code selection?	New: Code selection is based on total face-to-face and non-face-to-face time of the billing provider on the date of the encounter.	No change: Time may only be used for code selection when counseling and/or coordination of care dominates the service.