2025 Coding Guide-3: Evaluation and Management CPT Codes

3: Evaluation and Management CPT Codes

Pdf Summary

Evaluation and Management (E/M) codes are used to bill for visits and consultations provided by a physician. These codes are categorized based on the delivery site of service and level. E/M visits are determined by medical decision making or time, and include a medically appropriate history and/or examination. In 2021, changes were made to E/M codes to decrease administrative burden and unnecessary documentation. <br /><br />When billing for an E/M service, factors to consider include the patient type (new or established), setting of service (office, hospital, etc.), and level of E/M service provided. Levels of E/M service are determined by the level of medical decision making and/or the total time spent on the encounter. History and physical examination are still important, but are no longer used for code selection.<br /><br />Medical decision making (MDM) is based on the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management. Four levels of MDM are recognized: straightforward, low, moderate, and high. Time can also be used to select a code level, and includes activities such as reviewing tests, performing examinations, and counseling patients. <br /><br />Billing for both an E/M code and an electrodiagnostic testing code on the same day is appropriate in certain scenarios, such as when an evaluation and testing are both necessary for proper diagnosis and management. Examples include situations where a referring physician requests both an E/M and EDX evaluation, when the pretest history suggests an alternate diagnosis that requires an expanded evaluation, or when a patient is referred for EDX testing but additional evaluation is needed to determine the correct diagnosis. It is important to properly document and use the -25 modifier when billing for both services.

Keywords

E/M codes

medical decision making

billing

patient type

MDM levels

code selection

administrative burden

electrodiagnostic testing

modifier -25

documentation