Health Information Management

CMS and AMA documentation guidelines for E/M codes don't always agree

JustCoding News: Outpatient, December 16, 2009

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by Sharon Bolarakis, CPC, CPC-I

CMS and CPT reporting guidelines for evaluation and management (E/M) codes sometimes differ, which can be confusing to coders, who sometimes aren’t even aware of the variances. Also, it’s not unusual for confusion to ensue after physicians attend coding seminars and return to the office recounting coding advice that differs greatly from what the coding staff members know to be true.

Coders need to explore some of these guideline differences between CMS and CPT that pertain to E/M reporting to clarify any confusion that exists due to the inconsistencies. The guidelines coders should follow will depend on whether they are submitting the claim to Medicare or a commercial payer.

History of present illness (HPI)

HPI documentation is mandatory for most E/M services. The physician rendering services should obtain the HPI using the patient’s explanation for the reason of the visit on a specific date of service. CPT E/M guidelines list seven HPI descriptors, whereas CMS guidelines list eight.

In addition to duration, which is the descriptor that appears only on CMS’s list, guidelines in both the CPT Manual and CMS’ 1995 Documentation Guidelines for Evaluation and Management Services include the following seven HPI descriptors:

  • Location
  • Quality
  • Severity
  • Timing
  • Context
  • Modifying factors
  • Associated signs and symptoms


When a physician orders observation services for a patient, and the patient’s stay lasts longer than two consecutive days, the coding guidance between CMS and CPT is not the same. Keep in mind that observation encounters are considered outpatient services.

CPT requires coders to use unlisted CPT code 99499 for the days between admission and discharge from observation when the patient receives observation services for more than two days.

On the other hand, CMS states in the Medicare Claims Processing Manual chapter 12, section 30.6.8 that for the dates between the admission and discharge, the physician should report outpatient E/M visit codes using either codes 99201–99205 for new patients or codes 99211–99215 for established patients.

Admission and discharge on same day

CPT states that when a patient is admitted as an inpatient and discharged on the same date of service or referred to observation and discharged on the same date of service, providers should report codes 99234–99236.

CMS, however, directs providers to report admission codes 99221–99223 when the patient is admitted for fewer than eight hours. In addition, providers should not report discharge code(s) 99238 and 99239, unless the patient is discharged on a different date, according to CMS.

Emergency department (ED)

CPT codes 99281–99285, which are for outpatient services, were intended for physicians to use to report services they perform in the ED. Only one physician may report ED codes 99281–99285 for the same patient on the same date of service, according to CPT Assistant, July 2002.

In contrast, CMS guidelines state that two physicians may report ED codes for the same patient on the same date of service when consultation criteria are not met and the patient is not admitted.

Critical care

CPT allows providers to report ED visit codes 99281–99285 as well as critical care codes 99291–99292 for the same encounter. The documentation needs to include the critical care start and stop times to appropriately count the time and separate it from the ED visit.

However, CMS states in the Medicare Claims Processing Manual, chapter 12, section 30.6.9 that it will not reimburse providers separately for the ED and critical care visits on the same day when the same physician reports these services.

Preventive care service

CPT recognizes codes 99381–99397 for preventive care services, and most third-party payers will reimburse providers for these services annually per patient.

Although Medicare does not reimburse for preventive care services, it does allow a “Welcome to Medicare visit” or Initial Preventive Physical Exam for new beneficiaries during the first 12 months once they enroll in the Medicare program. Use HCPCS Level II code G0402 to report these visits.

Time-based billing

Medicare and CPT also differ when it comes to determining the time to report for encounters for which the physician spends more than half of the visit counseling or coordinating the care of the patient.

CPT allows providers to round up when reporting the physician’s time, whereas Medicare does not, according to Medicare Claims Processing Manual, chapter 12, section

For example, in the CPT Manual code descriptions, the typical time for code 99213 is 15 minutes and 10 minutes for code 99212.

For CMS, when the physician documents that he or she spent more than 50% of the 13-minute visit with the patient discussing the treatment options, you should report code 99212, not 99213.

However for this same encounter, CPT guidelines allow providers to round up and report CPT code 99213.

Editor's note: Sharon Bolarakis, CPC, CPC-I, is a coding and compliance consultant for Ethos Partners Healthcare Management Group where she performs audits and offers physician education and answers to reimbursement questions. She also answers coding questions for Ethos clients. E-mail her at

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