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E/M Coding Guide for Office Visits (99202–99215)

By Dynamic Medical Billing Solutions · Updated October 13, 2026 · 6 min read

Evaluation and management (E/M) codes for office visits are the most billed codes in medicine and the most audited. Since the 2021 guideline changes, the level of a visit is chosen by medical decision making (MDM) or total time. This guide explains both in plain English and flags the mistakes that cause denials and audit findings.

The Codes at a Glance

Patient type	Code range
New patient office or outpatient visit	99202–99205 (99201 was deleted in 2021)
Established patient office or outpatient visit	99211–99215

A new patient is one who has not received professional services from the physician or another physician of the same specialty and subspecialty in the same group within the past three years. Everyone else is an established patient. 99211 does not require a physician and has no MDM or time requirement beyond being a visit by clinical staff.

Two Ways to Choose the Level

For office and outpatient visits you may choose the level using either medical decision making or total time on the date of the encounter, whichever supports the higher level accurately. History and physical exam are still documented as medically appropriate, but they no longer determine the level.

Method 1: Medical Decision Making

MDM has three elements, and the level is set by meeting two of the three:

1. Number and complexity of problems addressed. From minimal, to low (for example, a self-limited problem or one stable chronic illness), to moderate (such as two or more stable chronic illnesses, or one chronic illness with exacerbation), to high (one or more chronic illnesses with severe exacerbation, or a threat to life or bodily function).
2. Amount and complexity of data reviewed and analyzed. Counts tests ordered and reviewed, external notes reviewed, independent historians and independent interpretation of tests or discussion of management with another clinician.
3. Risk of complications and morbidity of patient management. From minimal, to low, to moderate (for example, prescription drug management, or a decision about minor surgery with risk factors), to high (such as decision for major surgery, or drug therapy requiring intensive monitoring for toxicity).

MDM level	New	Established
Straightforward	99202	99212
Low	99203	99213
Moderate	99204	99214
High	99205	99215

The common error is documenting a long note that does not actually support moderate risk or a moderate number of problems. Length does not equal complexity; payers and auditors read for the decisions made.

Method 2: Total Time

If you code by time, count the total time the physician or other qualified health professional personally spends on the date of the encounter, including face-to-face and non-face-to-face work such as reviewing records, ordering tests, documenting and care coordination. It does not include time spent by clinical staff or time on a different date. Current CPT time thresholds (minimums that must be met or exceeded) are:

New	Time	Established	Time
99202	15 min	99212	10 min
99203	30 min	99213	20 min
99204	45 min	99214	30 min
99205	60 min	99215	40 min

Note that CPT revised the time descriptors in 2024 to minimums; before that they were ranges. Always check the current CPT book and the payer's own rules. Document the total time and what it was spent on; "30 minutes" alone is weak support.

Prolonged Services

When a visit goes well beyond the top-level time, a prolonged-service add-on may apply. Under CPT, 99417 is reported for each additional 15 minutes once the total time reaches 75 minutes for 99205 or 55 minutes for 99215. Medicare uses its own code, G2212, with different time thresholds. Prolonged services based on time cannot be combined with an E/M level chosen by MDM. Check payer policy before billing.

Modifier 25: Same-Day Procedures

When a physician performs a minor procedure and also provides a significant, separately identifiable E/M service on the same day, the E/M can be billed with modifier 25. The key words are "significant" and "separately identifiable": the E/M work beyond the usual pre-procedure assessment must be documented. Routine decision to perform a procedure does not justify a separate E/M. Payers often review modifier 25 claims closely. Specialties such as dermatology and orthopedics see this edit daily.

Common Errors That Lead to Denials and Audit Findings

• Upcoding to 99214/99215 by default. A pattern where nearly every visit is a high level draws attention. Payers compare you with peers in your specialty.
• Cloned notes. Copy-forward text that does not reflect the actual visit weakens support for any level.
• Counting problems that were not addressed. Only problems actually evaluated or managed at the visit count.
• Time claimed but not documented, or including time spent by staff.
• Wrong patient status. Billing a new-patient code for someone seen by the group within three years.
• Missing modifier 25 on same-day procedures, or using it without distinct documentation.
• Diagnosis codes that do not support the level, or that are not coded to the highest specificity.

Practical Tips for Practices

1. Train providers on MDM and on documenting decisions rather than volume.
2. Run a quarterly E/M level distribution report by provider and compare it with national specialty benchmarks and your own history.
3. Audit a small random sample of notes per provider each quarter and give feedback.
4. Keep payer-specific rules in a shared document; not every payer follows CPT or CMS in the same way.
5. Use an external coding audit when you want an unbiased view.

Accurate coding is also a compliance matter, because repeated overpayments can trigger repayment obligations. See our billing compliance page and the full physicians' billing services overview.

This guide is educational and not a substitute for the current CPT code book or payer policy. Code descriptors, time thresholds and payer rules change, so always verify against current sources.

Documentation Habits That Support the Level

Good E/M documentation is short, specific and shows reasoning. A few habits help whichever method you choose:

• State the problems addressed and their status (stable, worsening, new with uncertain prognosis) rather than listing every diagnosis in the chart.
• Record the data you reviewed or ordered, including outside notes, labs and imaging, and note when you discussed management with another clinician or used an independent historian.
• Name the management decisions and their risk, for example a prescription drug adjustment, a decision about surgery or a decision not to escalate because of risk factors.
• For time-based coding, record total time on the date of the encounter and briefly list what the time covered.
• Avoid copy-forward text. Each note should reflect that day's visit.

Templates in an EHR can help, but they should prompt the physician to add real clinical reasoning rather than auto-populate a high level.

Frequently Asked Questions

Can I choose between MDM and time for each visit?

Yes. For office and outpatient E/M visits you may select the level using either medical decision making or total time on the date of the encounter, whichever accurately supports the service. Do not mix the two methods within one claim.

Does time include staff time?

No. Only time personally spent by the physician or other qualified health professional on the date of the encounter counts, including non-face-to-face tasks such as reviewing records and documenting. Time spent by clinical staff does not count.

Is history and exam still required?

A medically appropriate history and examination should be documented, but they no longer determine the level of an office visit. The level is set by MDM or time.

When can I bill modifier 25?

When a significant, separately identifiable E/M service is performed on the same day as a minor procedure. The documentation should show the additional evaluation, beyond the usual pre-procedure assessment.

Who counts as a new patient?

A patient who has not received professional services from the physician, or another physician of the same specialty and subspecialty in the same group, within the past three years.