E/M 1


Evaluation and Management (E/M or ENM) – CPC Exam Preparation (2025)

What is E/M (Evaluation and Management)?

Evaluation and Management (E/M) services involve:

  • Evaluation: Assessing the patient’s condition, symptoms, and history
  • Management: Planning treatment, ordering tests, prescribing medications, and follow-up care

👉 E/M is not only consultation.
Consultation is just one type of E/M service.

Consultation vs E/M Visit

  • Consultation: Patient referred by another provider for opinion/advice
    • Traditional consult codes (99242–99245) are largely replaced by office E/M, especially for Medicare.
  • E/M Visit: Patient comes for diagnosis, treatment, or follow-up

📌 CPC Exam Note: Most consultation scenarios are now coded using office/outpatient E/M codes.

Patient Classification in E/M

E/M is classified by:

  1. Place of Service
  2. Patient Status

1. Outpatient / Office or Other Outpatient

Patient is not admitted to hospital.

New vs Established Patient (3-Year Rule)

  • New Patient
    👉 No professional service from the same specialty/subspecialty in the same group within past 3 years
  • Established Patient
    👉 Seen within the past 3 years

📌 Exam Tip: The 3-year rule applies only to outpatient E/M.

2. Inpatient / Hospital or Observation

Patient is admitted to hospital.

  • Initial Hospital Care: First visit during hospital stay
  • Subsequent Hospital Care: Follow-up visits during same admission

📌 Exam Tip: In inpatient E/M, no 3-year rule—only initial vs subsequent.

E/M Code Ranges (CPT 2025 – Exam Must-Know)

Office / Outpatient E/M (99202–99215)

New Patient

Code MDM Level Time
99202 Straightforward ≥15 min
99203 Low ≥30 min
99204 Moderate ≥45 min
99205 High ≥60 min

📌 99201 deleted (very important for CPC).

Established Patient

Code MDM Level Time
99211 Nurse visit No time/MDM
99212 Straightforward ≥10 min
99213 Low ≥20 min
99214 Moderate ≥30 min
99215 High ≥40 min

Inpatient / Observation E/M

Initial Hospital Care (99221–99223)

Code MDM Time
99221 Straightforward / Low ≥40 min
99222 Moderate ≥55 min
99223 High ≥75 min

Subsequent Hospital Care (99231–99233)

Code MDM Time
99231 Straightforward / Low ≥25 min
99232 Moderate ≥35 min
99233 High ≥50 min

Same-Day Admit & Discharge

  • 99234–99236 (time-based combined services)

How to Select the E/M Level (VERY IMPORTANT)

E/M level is selected by either:

  1. Medical Decision Making (MDM)
  2. Total Time on Date of Encounter

Medical Decision Making (MDM)

MDM has 3 elements (must meet 2 of 3):

  1. Problems Addressed

    • Minimal
    • Low
    • Moderate
    • High

  2. Data Reviewed/Analyzed

    • Tests
    • Notes
    • Independent historian
    • Independent interpretation

  3. Risk

    • OTC drugs → Low
    • Prescription drug management → Moderate
    • Surgery / severe condition → High

📌 Exam Tip: Prescription drug management = Moderate risk (frequently tested).

Time-Based Coding

  • Includes face-to-face + non-face-to-face work on same day
  • Only physician/QHP time counts
  • Staff time not included
  • Must meet minimum time

Prolonged Services

  • Add-on code 99417 (office/outpatient only)

Telemedicine E/M (2025 – CPC Aware)

Audio-Video (Synchronous)

  • Codes 98000–98007
  • Same MDM/time rules as office E/M

Audio-Only (Telephone)

  • Codes 98008–98015
  • Minimum 10 minutes required

Virtual Check-In

  • 98016 (5–10 min, established patient only)

📌 Document mode clearly (audio-video vs audio-only).

Modifiers Mentioned (High-Yield CPC Points)

Modifier Use
-24 Unrelated E/M during post-op period
-79 Unrelated procedure in post-op
-80 Assistant surgeon
-91 Repeat lab test
-59 / XS Distinct procedural service

Final CPC Exam Summary (Memorize This)

  • E/M selection = MDM OR Time
  • Outpatient new vs established = 3-year rule
  • Inpatient = initial vs subsequent
  • 99201 deleted
  • Prescription meds = Moderate risk
  • Telemedicine follows E/M rules
  • 99211 = nurse visit

“If you understand E/M logic clearly, you can easily score full marks in CPC.”

🔹 MDM TABLE – SUPER SIMPLIFIED (CPC READY)


MDM = 2 out of 3 must match


Element Straightforward Low Moderate High


Problems 1 self-limited 2 self-limited OR 1 stable 1 chronic w/ exacerbation OR ≥2 stable Life-threatening / severe

Data Minimal Limited Moderate Extensive

Risk Minimal Low Moderate High



🔑 Risk – MOST IMPORTANT (CPC Favorite)


OTC meds → Low


Prescription drug management → Moderate


Minor surgery (no risk factors) → Low


Major surgery → High


ER / hospitalization → High



📌 Shortcut Rule

👉 If prescription medication given → at least 99214 (OP)



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🔹 CPC PRACTICE QUESTIONS (WITH ANSWERS)


Q1


New patient, office visit

Acute bronchitis, chest X-ray ordered, antibiotic prescribed

Time: 32 minutes


✔ Answer: 99203

Why?


New patient


Low MDM


Time ≥30 min




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Q2


Established patient with diabetes & hypertension

Medication adjusted, lab results reviewed


✔ Answer: 99214

Why?


Chronic conditions


Prescription drug management → Moderate risk




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Q3


Established patient comes only for BP check by nurse


✔ Answer: 99211

Why?


No physician


No MDM / time required




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Q4


Patient admitted today, pneumonia, IV antibiotics started


✔ Answer: 99223

Why?


Initial inpatient


High risk (hospital admission + IV meds)




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Q5


Doctor spends 42 minutes with established patient

Problem is simple


✔ Answer: 99215

Why?


Time overrides MDM


≥40 min = highest level




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🔹 TRICKY E/M SCENARIOS (VERY EXAM-IMPORTANT)


❌ Trap 1: Long history & exam


CPC does NOT use history/exam for leveling anymore

✔ Only MDM or Time



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❌ Trap 2: Multiple diagnoses


More diagnoses ≠ higher code

✔ Risk & treatment matter



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❌ Trap 3: Lab review alone


Reviewing labs without management = Low MDM



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❌ Trap 4: Established vs New


Same doctor, same specialty within 3 years → Established Different specialty → New



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❌ Trap 5: Post-op visit


Routine post-op care → No E/M Unrelated problem → Modifier -24



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🔹 ONE-PAGE E/M CHEAT SHEET (MEMORIZE THIS)


Office / Outpatient


Patient Low Moderate High


New 99203 99204 99205

Established 99213 99214 99215



📌 Most Common CPC Answer: 99214



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Key Rules


E/M based on MDM or Time


Prescription meds = Moderate


Hospital admission = High


99201 deleted


99211 = nurse visit


Telemedicine uses same logic




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Fast Decision Flow (Exam Hack)


1. New or Established?



2. Outpatient or Inpatient?



3. Any prescription? → Moderate



4. Hospital / surgery? → High



5. Time higher? → Use time





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> “If prescription medication is present, think 99214 first.”





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