Evaluation and Management codes — commonly called E&M codes — are the most frequently used codes in all of outpatient medical billing. Every office visit, every hospital encounter, every consultation involves an E&M code. For the CPC exam, E&M coding is tested heavily and the 2023 revised guidelines changed how these codes are selected. This guide covers everything a beginner needs to understand E&M coding from the ground up.
What Are E&M Codes?
E&M codes describe physician or qualified healthcare professional visits and services — the face-to-face (or now telehealth) encounters where a patient is evaluated and managed. They cover office visits, hospital admissions, emergency department encounters, nursing facility visits, home visits, and more. E&M codes are found in the 99202–99499 range of the CPT codebook.
Unlike surgery codes that describe a specific procedure, E&M codes capture cognitive work — the thinking, evaluating, and decision-making that physicians do when they assess and treat patients.
New Patient vs Established Patient
The first determination in outpatient E&M coding is whether the patient is new or established to the practice. This matters because new patient visits have different code numbers and generally higher reimbursement than established patient visits.
- New patient: Has not received any professional services from the physician or another physician of the same specialty and subspecialty in the same group practice within the past three years
- Established patient: Has received professional services from the physician or another physician of the same specialty in the same group within the past three years
Office Visit Code Ranges
| Patient Type | Code Range | Levels |
|---|---|---|
| New patient — office or outpatient | 99202–99205 | 4 levels (level 1 deleted in 2021) |
| Established patient — office or outpatient | 99211–99215 | 5 levels |
Note that 99211 (established patient, minimal service) does not require physician presence — it is used for services performed by clinical staff under physician supervision, such as a nurse taking a blood pressure reading.
The 2023 E&M Guidelines — Medical Decision Making
Before 2021, E&M level selection was based on three components — history, physical examination, and medical decision making. The 2021 and 2023 guidelines eliminated the documentation-counting approach for office visits and replaced it with two options: Medical Decision Making (MDM) or Total Time.
Option 1 — Medical Decision Making (MDM)
MDM is based on three elements. The overall MDM level is determined by meeting or exceeding requirements in at least two of the three elements:
- Number and complexity of problems addressed
- Amount and/or complexity of data reviewed and analyzed
- Risk of complications and/or morbidity or mortality
| MDM Level | Code (New) | Code (Est.) | Problems | Data | Risk |
|---|---|---|---|---|---|
| Straightforward | 99202 | 99212 | Minimal | Minimal/none | Minimal |
| Low complexity | 99203 | 99213 | Low | Limited | Low |
| Moderate complexity | 99204 | 99214 | Moderate | Moderate | Moderate |
| High complexity | 99205 | 99215 | High | Extensive | High |
Option 2 — Total Time on the Date of Service
Physicians may also select the E&M level based on total time spent on the date of the encounter — including not just face-to-face time but also time spent reviewing records, ordering tests, coordinating care, and documenting. The time ranges for each level are specified in the CPT guidelines and vary between new and established patients.
Other Common E&M Categories
Beyond office visits, several other E&M categories are frequently tested:
- Hospital Inpatient (99221–99223, 99231–99233): Initial hospital care and subsequent hospital care
- Emergency Department (99281–99285): No new vs established distinction in the ED
- Critical Care (99291–99292): Time-based, requires direct delivery of high complexity care
- Preventive Medicine (99381–99397): Annual wellness visits by age group
- Nursing Facility (99304–99318): Care provided in skilled nursing or long-term care facilities