2024 E/M Documentation & Coding Changes Notes

Time - Single “minimum time threshold” to meet or exceed

• 2023 range vs 2024 minimum thresholds for total time on date of encounter (minutes):
  • 99202: $15-29$
  • 99203: $30-44$
  • 99204: $45-59$
  • 99205: $60-74$
  • 99212: $10-19$
  • 99213: $20-29$
  • 99214: $30-39$
  • 99215: $40-54$
• These thresholds represent the minimum total time spent on the date of the encounter to meet the code level when using time-based coding (2024 rules).

Multiple same-day E/M visits in hospital and nursing facility settings

• Per day basis: hospital inpatient/observation care services and nursing facility services are reported as a single service if multiple E/M visits occur on the same calendar date in the same setting.
• When selecting code level by MDM, aggregate MDM over the calendar date.
• When selecting by time, sum the time over the course of the day according to time-reporting guidelines.
• Split/Shared E/M Updates:
  • If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of face-to-face or non-face-to-face time performing the service.
  • In team-based care, substantive part of the MDM requires that the physician(s) or other QHP(s) make or approve the management plan for the number and complexity of problems addressed, and take responsibility for that plan with its inherent risk of complications and/or morbidity or mortality.
  • When reporting via MDM, the physician or QHP who performs the problems addressed and risk portions reports the service.

Data, MDM, and time-based code selection (MDM and time concepts)

• Medical Decision Making (MDM) components:
  • The number and complexity of the problems addressed at the encounter.
  • The amount of data to be analyzed (data can include medical records, tests, and other information reviewed during or for the encounter).
  • Tests, documents, orders, or independent medical histories; independent interpretation of tests.
  • The risk of complications due to morbidity or mortality of patient management decisions made at the visit.
• Time-based selection: time spent by the clinician can determine code level when guidelines are followed.
• In 2024, CMS emphasizes that more than half of the total time spent on split/shared visits or substantive MDM may determine the code level; time-based reporting is led by the professional spending the most time; MDM-based reporting depends on who approves and assumes responsibility for the plan.
• If data is used to select the MDM level, only the person who performs an independent interpretation or discussion of management or test interpretation may use those data categories.
• CMS requires modifier FS (Split or Shared E/M Visit) on claims to indicate multiple providers performed the visit.

E/M Section Updates (key changes in 2024)

• Nursing facility visits: five-minute time increase for two visits when reporting by time.
  • Initial visit (nursing facility): $50 ext{ minutes}$ total time.
  • Subsequent visit (nursing facility): $20 ext{ minutes}$ total time.
• A new add-on code: $+99459$ for pelvic examination; used with office/other outpatient, consultation, and preventive medicine codes; valued for practice expense only.
• Time-based thresholds and split/shared concepts apply across settings; the emphasis is on where the majority of time is spent and who takes responsibility for the care plan.

Critical Care is a Time-Based Code

• Critical care billing is based on time and requires documentation of medical necessity (management of any number of failing organ systems where immediate intervention would likely prevent deterioration or death).
• Qualifying conditions may include: cardiac arrest, cardiogenic shock, acute hepatic/renal failure, CNS disorders, post-traumatic complications, etc.
• Critical care time bundle includes the interpretation of most data (vital signs, lab values, EKGs, chest X-rays, other data), NG/OG placement, temporary transcutaneous pacing, ventilator management, and peripheral access procedures; these are included in the time calculation and cannot be billed separately.
• Procedures that can be billed separately outside critical care time: endotracheal intubation, pulmonary artery catheter placement, CPR, central/arterial line insertion, temporary pacemaker insertion, chest tube insertion.
• Time-based thresholds for Medicare critical care time:
  • 30-74 minutes: $99291 imes1$
  • 75-104 minutes: $99291 imes1 + 99292 imes1$
  • 105-134 minutes: $99291 imes1 + 99292 imes2$
  • 135-164 minutes: $99291 imes1 + 99292 imes3$
  • 165-194 minutes: $99291 imes1 + 99292 imes4$
• Medicare guidance requires the full additional 30 minutes to bill the next 99292 unit; e.g., ~104 minutes total time needed (74 + 30) to bill 99292 for a Medicare patient.
• Some payers may allow partial increments of the 30-minute interval (this could change in the future).
• Time spent on separately reportable procedures or services should not be included in the critical care time.

Total Duration of Critical Care — Time-based billing table

• Time ranges and corresponding billing: (illustrative mapping)
  • Less than $30$ minutes: use non-critical-care E/M codes such as 99221-99231, 99231-99233, or other appropriate E/M codes.
  • $30-74$ minutes: $99291 imes1$
  • $75-104$ minutes: $99291 imes1 + 99292 imes1$
  • $105-134$ minutes: $99291 imes1 + 99292 imes2$
  • $135-164$ minutes: $99291 imes1 + 99292 imes3$
  • $165-194$ minutes: $99291 imes1 + 99292 imes4$
• Modifier usage:
  • Modifier 24 (Unrelated evaluation and management service) or modifier FT (Unrelated evaluation and management visit) should be used when billing critical care to indicate that the critical care was unrelated to the procedure.
  • Modifier FT is mandatory on claims starting from March 1, 2022.
  • If critical care is performed in the postoperative period by a provider other than the surgeon, a modifier is not required; however, if care is fully transferred from the surgeon to an intensivist and the critical care is unrelated, modifiers 54 (Surgical care only) and 55 (Postoperative management only) must be reported.

Critical Care across multiple days and multiple clinicians

• Critical care services can span multiple days and are typically delivered in a dedicated area (ICU or ED).
• Undivided attention: while delivering critical care, the practitioner cannot attend to other patients simultaneously.
• Total time for critical care on a single date can be accumulated, whether continuous or non-continuous; if time crosses midnight and remains continuous, report the total units; if there is a disruption, a new initial service is reported.
• If a patient receives both critical care and another E/M visit on the same calendar date, both can be billed if documentation supports separate elements and reimbursement for both visits; in such cases, the later E/M visit may require modifier 25 on the hospital visit codes when appropriate.
• Critical care can be billed in addition to a procedure with a global surgical period if unrelated to the procedure; preoperative and postoperative critical care can be billed if the patient is critically ill and requires separate, distinct critical care.

Concurrent and split/shared critical care

• Concurrent care with multiple practitioners within the same specialty and group is allowed for follow-up critical care visits after an initial critical care visit (99291) if time is distributed over the date among practitioners.
  • Additional time intervals can be billed with 99292 by another practitioner within the same specialty and group (additional 30 minutes required).
• Concurrent care across different specialties is permitted if medically necessary and non-duplicative.
• If one practitioner initiates the initial critical care (99291) but another within the same specialty and group continues care, the total time spent by all practitioners is used to determine eligibility for 99291 and 99292.
• Split/shared critical care can be billed with Modifier FS (Split/shared E/M visit). Time can be counted only once when multiple providers jointly discuss the patient.

E/M Prolonged Service (add-on codes) and integration with time

• Prolonged services are add-on codes to E/M services and require the primary code to be selected based on time.
• Prolonged services may only be added to the highest-level code within the category and require a full 15 minutes of prolonged time; they do not follow the CPT mid-point time rule.
• Prolonged services work can include both face-to-face and non-face-to-face time.
• Prolonged services cannot be used on psychotherapy codes.
• No replacement code for G2212 exists for prolonged office or other outpatient E/M beyond the primary service time; 15-minute increments are listed as: 99417 (CPT) and G2212 (CMS) for hospitals; these are listed to be added to the primary service codes such as 99205, 99215, etc., as appropriate.
• Example time thresholds (illustrative):
  • 99205 with 60 minutes baseline; 15-minute add-ons via 99417; similarly for other high-level office/outpatient E/M services.
  • Inpatient/observations often use G0316 as the prolonged time add-on; thresholds vary by primary service code (e.g., 99223, 99233, 99236).

Prolonged service add-ons by setting (G-codes and CPT add-ons)

• Prolonged add-ons by primary E/M service (examples):
  • Primary E/M 99223 (Initial IP/Obs visit): Prolonged code G0316 with a threshold of 90 minutes.
  • Primary E/M 99233 (Subsequent IP/Obs visit): Prolonged code G0316 with a threshold of 65 minutes.
  • IP/Obs Same-Day Admission/Discharge (99236): Prolonged code G0316 with a threshold of 110 minutes.
  • IP/Obs Discharge Day Management (99238-9): No prolonged threshold listed (n/a).
  • Emergency Department Visits: No prolonged threshold listed (n/a).
  • Initial NF Visit (99306): Prolonged code G0317 with 95 minutes threshold.
  • Subsequent NF Visit (99310): Prolonged code G0317 with 85 minutes threshold.
  • NF Discharge Day Management: n/a.
  • Home/Residence Visit New Patient (99345): Prolonged code G0318 with 140 minutes threshold.
  • Home/Residence Visit Established Patient (99350): Prolonged code G0318 with 110 minutes threshold.
  • Cognitive Assessment and Care Planning (99483): Prolonged code G2212 with 100 minutes threshold.
  • Consults: Prolonged codes not listed (n/a).
• Prolonged home/residence evaluation and management service (G0318):
  • 99418: Prolonged inpatient/observation E/M beyond the primary service time (every additional 15 minutes, list separately, in addition to primary codes such as 99223, 99233, 99236, 99255, 99306, 99310).
  • G0316 (Prolonged hospital inpatient or observation E/M beyond the total time for the primary service) and related notes:
  • Do not report G0316 with other prolonged services for E/M 99358, 99359, 99417.
  • Do not report G0316 for any time unit less than 15 minutes.
  • Do not report G0318 on the same date of service as other prolonged services for evaluation and management (99358, 99359, 99417).

Add-On Complexity Code G2211

• G2211: Visit complexity inherent to evaluation and management associated with medical care services for ongoing care of a single, serious, or complex condition; used with office/outpatient E/M services.
• Key restrictions:
  • Cannot be billed when modifier 25 is appended to the base E/M code.
  • Intended for reporting longitudinal care and the ongoing patient-practitioner relationship.
• CMS clarification:
  • The provider-patient relationship is the focal point for determining whether G2211 can be billed.
  • If the practitioner is the focal point for all needed services (e.g., a primary care practitioner in ongoing care), G2211 could be billed.
  • If used for ongoing care of a single, serious and complex condition (e.g., sickle cell disease), G2211 could also be billed.

Reference links

• https://learn.pcc.com/wp/wp-content/uploads/PCC 2024 E M Coding Tool.pdf
• https://neolytix.com/e-m-changes-in-2024/
• https://www.medcentral.com/coding-reimbursement/accurately-report-e-m-visits-vaccinations-with-2024-cpt-updates
• https://learn.pcc.com/wp/wp-content/uploads/PCC 2024 E M Coding Tool.pdf
• https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
• https://www.aafp.org/pubs/fpm/issues/2023/0100/hospital-em-coding.html

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