Two office visits can carry the same documentation load and land on different E/M codes, because the current rules let you level a visit by medical decision making or by total time. Pick one basis per encounter and the level holds up. Blend the two in a single note and the reviewer has to guess which one you meant.
What this covers
- Since January 1, 2021, office and outpatient E/M codes 99202 through 99215 are leveled by medical decision making or by total time on the date of the encounter, not by history and exam.
- MDM uses three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of the management chosen. Two of the three must reach a level.
- Total time is a minimum that must be met, not a typical time. It counts only physician or qualified professional minutes on the date of the encounter, and clinical staff time never counts.
- Prolonged add-ons such as G2212 and 99417 exist only when the level was selected using total time, and Medicare’s threshold starts later than the CPT one.
- When a psychotherapy add-on such as 90833 is reported with an E/M visit, time cannot be used to select the E/M level at all.
The level is not the length of the note. It is the basis the clinician chose and the record left behind to support it.one basis per encounter, decided before the note is written
The basis is the first coding decision of the visit, not the last. It decides which documentation has to exist, which add-on codes are available, and which questions an auditor will ask. Practices that leave the choice to whoever codes the encounter at the end of the day are the ones that get downcoded.
One basis per visit, chosen before the note is written
The office and outpatient E/M family was rebuilt for dates of service on or after January 1, 2021. CPT deleted 99201 and rewrote 99202 through 99215 so the level comes from either medical decision making or total time on the date of the encounter. History and physical exam still have to be medically appropriate, and the 1995 and 1997 bullet guidelines stopped applying to these codes on that date.
The same structure spread across the rest of the E/M section for 2023. CMS states that as of January 1, 2023, most E/M visit families are leveled by MDM or by time. Emergency department visits are the exception, because time is not a descriptive component for those levels, so they stay on MDM.
The choice is made per encounter. The AMA’s guidance is to use the basis that accounts for the most relevant work. A short visit that turns on a difficult decision fits MDM. A long visit spent counseling a caregiver and coordinating with an outside clinician fits time. Choosing the higher of the two is not the problem. Billing the higher of the two without a record that supports that basis is.
A medically appropriate history and exam is still required by the code descriptors. What changed is that the extent of the history and the number of body systems examined no longer raise the level. A short note is not a compliance problem by itself. A short note that never describes the problem addressed is.
Getting the diagnosis and the procedure right is a medical coding job. Leveling the visit is a separate decision, and the clinician who saw the patient is the only person who can make it.
What medical decision making asks you to prove
MDM has three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications or death from the management chosen. Two of the three must reach a level for the visit to sit at that level. A moderate problem with limited data and low risk is a low-level visit.
| MDM level | Office codes | Problems addressed | Data reviewed and analyzed | Risk of management |
|---|---|---|---|---|
| Straightforward | 99202, 99212 | 1 self-limited or minor problem | Minimal or none | Minimal risk from testing or treatment |
| Low | 99203, 99213 | 2 or more self-limited problems, 1 stable chronic illness, or 1 acute uncomplicated illness or injury | 2 from reviewed notes, reviewed results, ordered tests, or an independent historian | Low risk from testing or treatment |
| Moderate | 99204, 99214 | Chronic illness with exacerbation or progression, 2 or more stable chronic illnesses, an undiagnosed new problem with uncertain prognosis, an acute illness with systemic symptoms, or an acute complicated injury | 3 from the first category, an independent test interpretation, or a management discussion with an outside professional | Moderate risk. Prescription drug management is the common example |
| High | 99205, 99215 | Chronic illness with severe exacerbation or progression, or an illness that threatens life or bodily function | Extensive: 2 of the 3 data categories must be met | High risk. Intensive toxicity monitoring, the decision to hospitalize, or the decision not to resuscitate |
The problems element decides most behavioral health visits
A problem is addressed when it is evaluated or treated at the encounter by the clinician reporting the service. A diagnosis carried in the history and not worked at the visit does not count. A referral without an evaluation does not count. A note stating that another professional manages the problem does not count.
The independent historian definition matters in developmental and psychiatric care. It covers a parent, guardian or witness who supplies a history because the patient cannot give a complete or reliable one, for reasons of developmental stage, dementia or psychosis. A combination of a reviewed note, an ordered test and an independent historian reaches the first category threshold at the moderate level.
Risk is documented, not assumed. Prescription drug management is a moderate-risk example. Drug therapy requiring intensive monitoring for toxicity, a decision regarding hospitalization, and a decision not to resuscitate are high-risk examples. A psychiatric illness with potential threat to self or others sits at the high level for problems addressed.
When total time is the cleaner basis
Time removes the argument about data and risk. It also has a hard edge. The time in the descriptor is a minimum that must be met, not a typical time, and the clinician has to provide the services for the full period.
| Code | Patient | Total time on the date of the encounter |
|---|---|---|
| 99202 | New | 15-29 minutes |
| 99203 | New | 30-44 minutes |
| 99204 | New | 45-59 minutes |
| 99205 | New | 60-74 minutes |
| 99212 | Established | 10-19 minutes |
| 99213 | Established | 20-29 minutes |
| 99214 | Established | 30-39 minutes |
| 99215 | Established | 40-54 minutes |
Total time is the face-to-face and non-face-to-face time the physician or other qualified health care professional personally spends on the date of the encounter. It includes preparing for the visit, reviewing a separately obtained history, the examination, counseling the patient or caregiver, ordering medications and tests, communicating with other clinicians when that is not reported separately, documenting in the record, and care coordination.
It excludes three things that catch practices. Time spent by clinical staff never counts. Time on a service that is reported separately does not count, so an ABA treatment session or a psychotherapy add-on cannot be folded into the E/M total. Review of records on another date does not count, because the window is the date of the encounter.
CMS asks for either start and stop times or the total time in the record when time selects the level, and a range such as 30 to 40 minutes is neither. The usual midpoint rule for timed services does not apply here, and the services must be provided for the full time billed.
99211 sits outside the choice. It describes an established patient visit that may not require the presence of the physician or qualified professional, and it fits the case where that clinician supervises clinical staff who perform the face-to-face work.
Prolonged services only exist on the time path
Prolonged office visits split by payer. Medicare uses HCPCS code G2212, and the CPT counterpart for other payers is code 99417. Both are add-ons to the highest-level office visit, and both require that the level was selected using total time.
| Codes reported | Total time required on the date of service |
|---|---|
| 99205 alone | 60-74 minutes |
| 99205 and G2212, one unit | 89-103 minutes |
| 99205 and G2212, two units | 104-118 minutes |
| 99215 alone | 40-54 minutes |
| 99215 and G2212, one unit | 69-83 minutes |
| 99215 and G2212, two units | 84-98 minutes |
| 99215 and G2212, three or more units | 99 minutes or more |
The two codes start counting at different points, and that is where claims fail. CPT 99417 begins 15 minutes past the minimum of the level five code, which is 75 minutes for 99205 and 55 minutes for 99215. Medicare’s G2212 begins 15 minutes past the maximum, at 89 minutes and 69 minutes. Billing 99417 on a Medicare claim is a denial.
If the level was selected by medical decision making, there is no prolonged service to report, however long the visit ran. Medicare also bars G2212 for less than 15 additional minutes and on the same date of service as 99358, 99359, 99415 or 99416.
Both prolonged codes sit inside the practice’s medical coding and billing workflow, and both need the payer’s own code, not a default.
The behavioral health rule that removes time from the table
One rule overrides the time option in a large share of behavioral health visits. When a psychotherapy add-on is reported with an E/M service, CPT instructs that time may not be used as the basis of E/M code selection, and prolonged services may not be reported. The add-ons are 90833 at 30 minutes, 90836 at 45 minutes and 90838 at 60 minutes.
CMS states the same restriction in the psychiatry and psychology billing and coding article, which carries a revision effective date of January 1, 2026: time spent on the E/M service is not included in the time used for the psychotherapy service, and time may not be used as the basis of E/M code selection. The E/M level has to come from MDM alone.
Documentation is where this rule is tested. The time for each service has to be clear in the record by number of minutes or start and stop times, separately for the E/M and for the psychotherapy. A single entry reporting 45 minutes of face-to-face time for the encounter proves neither service. These add-ons are payable only to physicians, physician assistants, nurse practitioners and clinical nurse specialists.
ABA treatment codes follow a different path and meet the same wall. Codes 97153 and 97155 are 15-minute treatment codes, one for technician-delivered treatment and one for protocol modification by the qualified professional. Their time is reported on its own line and cannot be added to E/M total time.
How mixing the two bases fails an audit
Most failures fall into a short list of patterns.
- The note states a total time and also argues MDM elements, and the two point at different levels.
- The time is documented without saying what filled it, or as a range such as 30 to 40 minutes.
- Clinical staff minutes are inside the total.
- Records reviewed the day before the visit are counted toward the date of the encounter.
- The E/M total includes minutes from a psychotherapy add-on or an ABA treatment session.
- A prolonged unit is billed on a visit leveled by MDM.
None of these is a coding error in the narrow sense. They are documentation errors that make a correct code unsupportable.
Give clinicians one field that selects MDM or total time, and make the rest of the template follow that choice. A template that invites both produces both.
When time selects the level, capture start and stop times or one specific total on the date of service, and name the activities that filled it.
For psychotherapy with E/M, require minutes for the E/M and minutes for the psychotherapy as separate entries, and select the E/M level from MDM.
Sample notes and ask one question: does the record support the basis the practice billed? Report the answer as an error rate by clinician and by code.
- Every E/M note names one basis: MDM or total time.
- An MDM note documents the problem addressed, the data reviewed with its source, and the risk of the plan.
- A time note carries a specific total or start and stop times for the date of the encounter.
- No clinical staff minutes, travel, or separately reported service time sits inside the total.
- Prolonged units appear only on visits leveled by time, in the payer’s own code.
- Psychotherapy add-ons carry separate minutes for each service.
Chart auditing turns this from an opinion into a number. Scoring each note against the basis it claims shows whether the practice bills what it can defend, and it belongs inside a comprehensive chart auditing routine.
E/M leveling questions billing teams ask
No. The level is set by one basis per encounter, either medical decision making or the total time on the date of the encounter. Both may appear in the record, but the note has to make clear which one selected the level. A note that argues both and points at two different levels is the pattern auditors downcode.
A 99214 covers 30 to 39 minutes of total time on the date of the encounter when time is the basis for the level. The same code is also correct for a moderate level of medical decision making, which can occur in a much shorter visit. The time range is a threshold that must be met, not an average.
Yes, when the physician or other qualified health care professional does the documenting. Reviewing tests, ordering medications, coordinating care and writing the note all count if they happen on the date of the encounter. Time spent by clinical staff, time on separately reported services, travel and general teaching do not count.
Only when the office visit level was selected using total time and the visit ran past the maximum of the level five code by at least 15 minutes. That means 89 to 103 total minutes with 99205, or 69 to 83 total minutes with 99215, for the first unit. Each further unit needs another complete 15 minutes.
CPT instructs that time may not be used as the basis of E/M code selection when a psychotherapy add-on such as 90833, 90836 or 90838 is reported. The E/M level has to come from medical decision making, and prolonged services cannot be reported. Each service still needs its own minutes in the record.
An independent historian is a person who supplies a history the patient cannot give, such as a parent or guardian in a developmental evaluation. It counts as one element in the data category. Two elements reach the limited data threshold at a low level, and a combination of three reaches the moderate first-category threshold.
The bottom line
The current E/M rules hand the practice a choice, and the choice is the record’s problem. Time has to be counted and written down. MDM has to be argued from the problems addressed, the data reviewed and the risk of the plan. Pick one basis per visit, document it, and the level survives review.
Which basis is your practice actually billing?
We read a sample of your E/M notes against the basis each one claims, separate MDM from time, and show you where the record and the code disagree. You get the error rate by clinician and a short list of template fixes.
Request a free E/M documentation auditThis article describes E/M coding rules in effect for dates of service in 2026 and is not a coverage guarantee; confirm the current CPT descriptors and each payer’s policy before changing how your practice levels visits.
