E/M Code Calculator — Information & Guidance
This is the authoritative reference for the calculator’s (info) links. All sections are deep‑linkable and header-safe.
Table of Contents
- Encounter Type
- Total Time Spent (minutes)
- Medical Decision Making (MDM)
- Only Two out of Three are Needed
- Number and Complexity of Problems Addressed
- Self-limited or minor problem(s)
- Stable chronic illnesses
- Acute, uncomplicated illness or injury
- Chronic illnesses with exacerbation, progression, or side effects of treatment
- Severe exacerbation of chronic illness
- Undiagnosed new problem with uncertain prognosis
- Acute illness with systemic symptoms
- Acute complicated injury
- Acute or chronic illness or injury posing a threat to life
- Amount and/or Complexity of Data to be Reviewed and Analyzed
- Review of prior external note(s) from each unique source
- Review of the result(s) of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian(s)
- Independent interpretation of a test performed by another physician/other QHP
- Discussion of management or test interpretation with external physician/other QHP/appropriate source
- Risk of Complications and/or Morbidity or Mortality
- Minimal risk
- Low risk
- Moderate Risk Criteria
- High Risk Criteria
- Drug therapy requiring intensive monitoring for toxicity
- Decision regarding elective major surgery with identified patient or procedure risk factors
- Decision regarding emergency major surgery
- Decision regarding hospitalization or escalation of level of hospital care
- Decision for DNR or for de-escalation of care
- Parenteral controlled substances
- High risk by clinical judgment
Encounter Type
New Office Patients
These codes are used to report E/M services for new office patients. There used to be five levels of care for these encounters, but now there are only four. There is significant variability in payment, depending upon the code billed, so it is important to select the level of care which matches the clinical circumstances of the patient in order to optimize reimbursement.
For these encounters, the level of care may be selected based on the MDM required for the visit OR based on time spent.
Established Office Patients
These codes are used to report E/M services for established office patients. There are five levels of care. There is significant variation in payment, depending upon the code billed, so it is important to select the level of care which matches the clinical circumstances of the encounter in order to optimize reimbursement.
For these encounters, the level of care may be selected based on the MDM required for the visit OR based on time spent.
Initial Hospital Care
These codes are used to report initial hospital care services (otherwise known as admission H&Ps). These codes are used for both inpatients and observation care patients. There are three levels of care for these services. There is significant variability in payment, depending upon the code billed, so it is important to select the level of care which matches the clinical circumstances of the patient to optimize reimbursement.
For these encounters, the level of care may be selected based on the MDM required for the visit OR based on time spent.
Subsequent Hospital Care Services
These codes are used to report subsequent hospital care services (also known as hospital progress notes). Use these codes to report subsequent hospital care services for both inpatients and observation care patients. There are three levels of care for these services. There is significant variability in payment, depending upon the code billed, so it is important to select the level of care which matches the clinical circumstances of the patient to optimize reimbursement.
For these encounters, the level of care may be selected based on the MDM required for the visit OR based on time spent.
Emergency Department E/M Services
These codes are used to report emergency department E/M services. There are five levels of care. There is significant variability in payment, depending upon the code billed, so it is important to select the level of care which matches the clinical circumstances of the patient to optimize reimbursement.
For these encounters, the level of care may be selected based on the MDM required for the visit OR based on time spent.
Consult Services
Medicare stopped paying for consult services on January 1, 2010. Some private insurers continue to pay for these services. These codes are used to report consult services in both the outpatient and inpatient settings. There used to be five levels of care for these services, but now there are only four.
Reimbursement and national utilization data for these services are not available because consults are no longer recognized by Medicare.
For these encounters, the level of care may be selected based on the MDM required for the visit OR based on time spent.
Initial Nursing Facility Care Services
These codes are used to report initial nursing facility care services. Initial nursing facility care services provide the initial comprehensive assessment during which the physician completes a thorough evaluation, develops a plan of care and writes or verifies admitting orders for the nursing facility resident.
There are three levels of care for these services. There is significant variability in payment, depending upon the code billed, so it is important to select the level of care which matches the clinical circumstances of the patient to optimize reimbursement.
For these encounters, the level of care may be selected based on the MDM required for the visit OR based on time spent.
Subsequent Nursing Facility Care Services
These codes are used to report subsequent nursing facility care services. Subsequent nursing facility care services are defined as encounters that take place in a nursing facility after the initial nursing facility care evaluation.
There are four levels of care for these services. There is significant variability in payment, depending upon the code billed, so it is important to select the level of care which matches the clinical circumstances of the patient to optimize reimbursement.
For these encounters, the level of care may be selected based on the MDM required for the visit OR based on time spent.
Critical Care
Critical care is the direct delivery by a physician of medical care for a critically ill or injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.
Any physician or NPP can bill for critical care. Critical care does NOT necessarily have to take place in the intensive care unit.
Coding for Critical Care: Two Time-Based Codes
- 99291 — Used for the first hour
- 99292 — Used for each additional 30 minutes
Total Time Spent (minutes)
When time is used for reporting E/M services codes, the time defined in the service descriptors is used for selecting the appropriate level of services. The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health care professional and the patient and/or family/caregiver.
For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff). It includes time regardless of the location of the physician or other qualified health care professional (e.g., whether on or off the inpatient unit or in or out of the outpatient office). It does not include any time spent in the performance of other separately reported service(s) or procedure(s).
Physician or other qualified health care professional time includes the following activities, when performed:
- preparing to see the patient (e.g., review of tests)
- obtaining and/or reviewing separately obtained history
- performing a medically appropriate examination and/or evaluation
- counseling and educating the patient/family/caregiver
- ordering medications, tests, or procedures
- referring and communicating with other health care professionals (when not separately reported)
- documenting clinical information in the electronic or other health record
- independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- care coordination (not separately reported)
Do not count time spent on the following:
- the performance of other services that are reported separately
- travel
- teaching that is general and not limited to discussion that is required for the management of a specific patient
Documentation of Time: If you are billing for an E/M service based on time (as opposed to based on the MDM), you must document time spent in the note and also include a brief description of the activities performed. For example, if billing for a 99214 established office visit based on time, you might say, “I spent a total of 30 minutes today before, during and after the visit reviewing labs, examining the patient, discussing treatment options and documenting the encounter.”
Medical Decision Making (MDM)
Only Two out of Three are Needed
To qualify for any given level of MDM, only two out of the three dimensions are required; you don’t need the problems, the data and the risk — you need two out of three. Use the highest two dimensions present during the encounter. Example: if problems are low but data and risk are moderate, the overall MDM is moderate (based on data + risk).
Number and Complexity of Problems Addressed
One element used in selecting the level of service is the number and complexity of the problems that are addressed at the encounter. Multiple new or established conditions may be addressed at the same time and may affect MDM. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. Comorbidities and underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Therefore, presenting symptoms that are likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.
Problem addressed: A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the reporting clinician. Referral without evaluation does not qualify as being addressed or managed. For hospital inpatient and observation care services, the problem addressed is the problem status on the date of the encounter.
Self-limited or minor problem(s)
A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.
Stable chronic illnesses
A problem with an expected duration of at least one year or until the death of the patient. “Stable” is defined by the patient’s treatment goals; a patient not at goal is not stable even if unchanged.
Acute, uncomplicated illness or injury
A recent or new short-term problem with low risk of morbidity for which treatment is considered. Little to no risk of mortality with treatment, and full recovery without functional impairment is expected.
Chronic illnesses with exacerbation, progression, or side effects of treatment
A chronic illness that is acutely worsening, poorly controlled or progressing, which requires additional supportive care or attention to treatment, but does NOT require consideration of hospital level care.
Severe exacerbation of chronic illness
Severe exacerbation/progression or severe side effects of treatment that may pose significant risk of morbidity and for which hospital level care may be considered.
Undiagnosed new problem with uncertain prognosis
A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.
Acute illness with systemic symptoms
An illness that causes systemic symptoms and has a high risk of morbidity without treatment. Systemic symptoms may be general (fever, fatigue) or single-system.
Acute complicated injury
An injury requiring evaluation of body systems beyond the directly injured organ, extensive injury, and/or multiple treatment options associated with morbidity.
Acute or chronic illness or injury posing a threat to life
A condition that, without treatment, poses a near‑term threat to life or bodily function (or is significantly probable and managed as such).
Amount and/or Complexity of Data to be Reviewed and Analyzed
This category refers to the amount and/or complexity of data to be reviewed and/or analyzed during the encounter, including medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed, interprofessional communications not separately reported, and interpretation of tests not separately reported.
Review of prior external note(s) from each unique source
External = another physician/QHP in a distinct group, specialty/subspecialty, or unique entity. Review of all materials from a unique source counts as one element.
Review of the result(s) of each unique test
Tests include imaging, laboratory, psychometric, or physiologic data. A panel is one test. Multiple results of the same unique test count once. Pulse oximetry is not a test for this element.
Ordering of each unique test
Ordering is part of data reviewed. Considered‑but‑not‑selected tests after shared decision making may be documented.
Assessment requiring an independent historian(s)
An individual providing history in addition to the patient (e.g., parent/guardian/surrogate) when the patient cannot provide a complete/reliable history or a confirmatory history is necessary. Translation alone does not qualify.
Independent interpretation of a test performed by another physician/other qualified health care professional
Interpretation of a test for which a CPT exists and a report is customary. Does not apply when you are billing the test’s professional component. Brief documentation of your interpretation suffices.
Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source
Requires an interactive exchange (direct; not via staff/trainees). May be asynchronous but should be timely (e.g., within 1–2 days) and used in the encounter’s decision making.
Risk of Complications and/or Morbidity or Mortality
This category refers to the risk of complications and/or morbidity or mortality of patient management. This includes decisions made at the encounter associated with diagnostic procedure(s) and treatment(s). This includes the possible management options selected and those considered but not selected after shared decision making with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment.
Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purpose of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.
Definitions of Risk Elements
Morbidity: A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.
Prescription drug management: Usually refers to starting, stopping or adjusting the dosage of a medication during an E/M service; may include continuing a medication unchanged when risks/benefits are explicitly weighed and documented with a monitoring plan.
Surgery — Minor/Major; Elective/Emergency; Patient/Procedure Risk Factors: “Minor” vs “major” follows common clinical meaning; elective is planned; emergency is immediate/urgent. Risk factors are those relevant to the patient/procedure; evidence-based calculators may be used but are not required.
Minimal risk
Typically self‑care or conservative management (e.g., rest, simple dressings) with no prescription drug management and no significant diagnostic/therapeutic risk.
Low risk
Low‑risk management such as OTC meds, minor procedures without risk factors, or routine testing; minimal potential for morbidity with treatment.
Moderate Risk Criteria
Any of the following generally qualifies as moderate risk:
Prescription drug management
Counts when: Start/stop/adjust a prescription, or explicitly document risk–benefit analysis to continue unchanged despite non‑ideal findings, with a plan for monitoring.
Doesn’t count: OTC-only meds; passive med list review; continuing meds without reasoning.
Doc tip: “Continue lisinopril despite mild ↑Cr; repeat BMP in 1 week; monitor.”
Decision regarding minor surgery with identified patient/procedure risk factors
Counts when: You document the decision (YES or NO) and specify pertinent risk factor(s) (e.g., anticoagulation, poor glycemic control, anatomic complexity).
Doesn’t count: Minor procedure decisions without risk factors.
Doc tip: “Discussed I&D; deferred today due to warfarin (INR 3.1); will bridge and schedule.”
Decision regarding elective major surgery without identified risk factors
Counts when: Decision (YES or NO) for an elective major procedure with no additional patient/procedure risk factors.
Doesn’t count: Vague future consideration; emergency major surgery (that’s high risk).
Doc tip: “Elective TKA recommended; proceeding; no added risk factors.”
Diagnosis or treatment significantly limited by social determinants of health (SDOH)
Counts when: Access/safety/economic barriers materially change the plan (e.g., no refrigeration for insulin; pharmacy closure; unstable housing limits wound care; food insecurity affects anticoag diet).
Doesn’t count: Generic SDOH mentions that don’t alter management.
Doc tip: “Unstable housing—cannot maintain wound checks; plan oral abx + daily clinic nurse visits.”
Moderate risk by clinical judgment
Counts when: None of the above apply, but the encounter is reasonably judged moderate risk given condition severity/trajectory and chosen management. Document succinct clinical reasoning.
High Risk Criteria
Any of the following generally qualifies as high risk:
Drug therapy requiring intensive monitoring for toxicity
Therapeutic agents with potential for serious morbidity/death; monitoring is for toxicity (not primarily efficacy). Acceptable monitoring: lab, physiologic, imaging. History/exam alone doesn’t qualify. Long‑term intensive monitoring is not less than quarterly. Examples that do not qualify: routine glucose checks during insulin titration; annual electrolytes on a diuretic. Example that does qualify: close electrolyte/renal monitoring when diuretics are actively adjusted (e.g., daily inpatient; weekly outpatient) — document the rationale.
Decision regarding elective major surgery with identified patient or procedure risk factors
Document the decision (YES or NO) and the risk factors increasing procedural risk.
Decision regarding emergency major surgery
Document the decision (YES or NO).
Decision regarding hospitalization or escalation of level of hospital care
Credit applies whether the patient accepts or declines, provided the decision and rationale are documented (e.g., goals of care, patient preference).
Decision for DNR or for de-escalation of care
Change in code status or shift to comfort‑focused care due to poor prognosis or clinical decline. Not applicable to routine discussions when the patient is stable.
Parenteral controlled substances
Active treatment with IV or SQ controlled substances (e.g., IV lorazepam for alcohol withdrawal; parenteral opioids for severe pain). Document your decision to continue/start/adjust/stop.
High risk by clinical judgment
When specific bullets above do not apply but, in the examiner’s reasoned judgment, the encounter is high risk. Justify with clinical reasoning/differential/red flags.