E/M CPT Codes (2025 Edition)
Frequently Used and Tricky E/M CPT Codes (2025 Edition)
Evaluation and Management (E/M) codes are fundamental to medical coding.
Some E/M codes are more frequently used or challenging than others.
Focus is given to codes where selecting the correct level of service or meeting documentation requirements often presents difficulties.
Major E/M guideline changes took effect in 2021–2023.
Code selection can be based on Medical Decision Making (MDM) or total time.
Deletion of low-level codes occurred.
The CPT 2025 code set introduced new telemedicine E/M codes.
Quick Reference Summary Table
99214 - Office Visit (Est. Patient, Level 4)
Description: Moderate complexity E/M for an established patient; typically 30 minutes by time.
Usage: Most-used outpatient code (98.5M Medicare claims in 2022).
Requirement: Moderate MDM is required.
Pitfalls:
Frequently upcoded without sufficient documentation.
63% of 99214 improper payments were due to incorrect coding.
Documentation must justify moderate complexity (e.g., multiple problems or Rx management) or ≥30 min time.
99213 - Office Visit (Est. Patient, Level 3)
Description: Low complexity E/M for established patient (~20 min).
Usage: Very common code (2nd only to 99214, with 73.6M Medicare claims in 2022) for routine or minor visits.
Requirement: Straightforward/low MDM.
Pitfalls:
Risk of undercoding or overcoding on the 3–4 border.
Documentation should support only low complexity (e.g., stable single problem) if using 99213.
Often used as a “default” code; be careful not to bill 99213 when the visit actually meets 99214 criteria (or vice versa).
99215 - Office Visit (Est. Patient, Level 5)
Description: High complexity E/M for established patient (typically 40–54 min by time).
Usage: Infrequently used (historically ~5% of office visits) but high-stakes.
Requirement: Requires high complexity MDM (e.g., severe exacerbation of illness or life-threatening problem) or ≥40 min of total time.
Pitfalls:
Difficult to meet criteria.
Providers may mistakenly bill 99215 based on multiple diagnoses/meds even if none are acutely severe.
Audits target 99215, with ~65% error rates in reviews.
Documentation must clearly demonstrate a high level of risk, data review, or decision complexity, or use time appropriately.
99204 - Office Visit (New Patient, Level 4)
Description: Moderate complexity E/M for a new patient (~45 min by time).
Usage: Most common new-patient code (12.3M Medicare claims in 2022).
Requirement: Moderate complexity (similar in MDM to 99214).
Pitfalls:
Documentation must support moderate MDM (e.g., chronic illness with exacerbation, or prescription drug management).
Common errors include incomplete history of present illness or missing exam elements.
Avoid upcoding to 99205 without meeting high complexity criteria.
99205 - Office Visit (New Patient, Level 5)
Description: High complexity E/M for new patient (~60+ min).
Usage: Used for the most complex new patient visits.
Requirement: Requires extensive data review, high-risk decisions, or ≥60 min time.
Pitfalls:
Rarely justified; ensure a comprehensive workup is documented (e.g., multiple tests, consultations, or decision for hospital admission).
Often under-used due to fear of audits – but if time/MDM qualify, it should be billed to capture work done.
Conversely, do not use if criteria aren’t met; like 99215, it’s scrutinized for upcoding.
99223 - Hospital Inpatient Initial, Level 3
Description: High complexity initial hospital visit (typically 75+ min).
Usage: Highest-level initial hospital code, often used for very sick admissions.
2023 update: Combined “observation” and inpatient services, so 99223 now applies to both inpatient & observation high-level admits.
Pitfalls:
High error rate – one audit found 78% of 99223 claims were downcoded or denied for lack of supporting documentation.
Needs comprehensive workup and high complexity MDM (e.g., patient in significant distress or with severe exacerbation).
Common mistake: Billing 99223 for relatively routine admissions – use 99221–99222 for lower complexity.
99233 - Hospital Inpatient Subsequent, Level 3
Description: High complexity subsequent day visit (hospital follow-up).
Usage: Frequently misused on hospital rounds.
It’s intended for unstable or deteriorating patients – “Bill 99233 only for patients with a deteriorating condition,” not for stable check-ups.
Pitfalls:
Many physicians overcode to 99233; stable patients with multiple chronic issues usually merit 99232 (moderate), not 99233.
Red flag pattern: consecutive days of 99233 followed by discharge next day (if truly that unstable, a sudden discharge is unlikely).
Documentation must clearly show worsening status or highly complex decision-making.
Under 2021+ rules, ensure MDM is high complexity or time beyond 35 minutes.
99232 - Hospital Inpatient Subsequent, Level 2
Description: Moderate complexity subsequent visit.
Usage: Workhorse hospital follow-up code.
Used for the typical daily progress note on a patient who is improving or stable with moderate issues.
Pitfalls:
Sometimes undercoded (downgraded to 99231) if documentation is too sparse – include relevant interval history, exam, and active management of problems.
Conversely, avoid reflexively using 99232 if patient actually deteriorated (consider 99233 in those cases).
Document any new complaints or changes – this supports the moderate complexity level.
99285 - Emergency Dept. Visit, Level 5
Description: High complexity ED visit for a patient (no distinction new/established).
Usage: Most common ED code (about 40% of ED E/M services) – used for severe presentations (e.g., chest pain rule-outs, complex trauma).
Pitfalls:
Must meet high complexity MDM: extensive data (labs, imaging, consults) and high risk (e.g., threat to life or limb).
Incomplete documentation can lead to downcoding.
Ensure charting captures all tests, treatments, and the critical thought process (e.g., differential diagnoses, decisions to admit or aggressive treatments) to support 99285.
99284 - Emergency Dept. Visit, Level 4
Description: Moderate complexity ED visit.
Usage: Another widely used ED code (~30% of ED cases).
Covers moderate severity issues (e.g., fractures, moderate asthma attack).
Pitfalls:
The MDM must be clearly moderate – include documentation of multiple tests or diagnoses and moderate risk interventions (e.g., IV meds or prescription drug management).
If documentation is thin, payers may downcode it to 99283.
Remember that even an OTC medication given for an acute condition counts as prescription management (thus meeting moderate risk) – don’t undersell the level if appropriate care was provided.
99291 - Critical Care, first 30–74 min
Description: Critical care service (first hour) for a patient in life-threatening condition.
Used when managing a critically ill or injured patient (e.g., shock, respiratory failure) requiring constant attention.
Pitfalls:
Time tracking and exclusivity – must document total critical care time (start/end times or total minutes).
A minimum of 30 minutes is required to bill 99291.
Do not bill a separate E/M on the same day by the same provider for the same patient if 99291 is used (critical care includes the E/M work).
Also ensure the nature of illness is truly critical and interventions (e.g., vasopressors, ventilator management) are documented – reviewers will deny 99291 if the scenario doesn’t warrant critical care.
Use add-on 99292 for each additional 30 min beyond the first 74 min.
99242–99245 Consultation Visits (Office & Inpatient)
Description: E/M consults requested by another provider (outpatient 99242–99245; inpatient 99252–99255).
Often used by specialists.
2023 changes: CPT deleted the lowest-level consult codes (99241, 99251) and revised guidelines – now 4 levels aligning with the four MDM levels.
Pitfalls:
Medicare will not pay for consult codes (since 2010), so use other E/M codes for Medicare patients.
For other payers, documentation must show it’s a consult: include the requesting provider, reason for consult, and that you provided a report back. Failing to document the request/report can invalidate the consult code.
Also, don’t confuse a transfer of care with a consult (CPT 2023 removed transfer-of-care language to reduce confusion).
Always select the consult level by MDM or time just as with other E/M services under current rules.
99417 Prolonged Service (Outpatient)
Description: Each 15 min of prolonged E/M service beyond the highest office/outpatient visit (when using time).
New in 2021, used alongside 99205 or 99215 (and certain others) to capture time beyond the usual maximum.
Pitfalls:
Can only be reported after the base code’s time threshold is exceeded by ≥15 min. For example, 99215 covers up to 54 min; 99417 kicks in at 55+ minutes.
Do not use 99417 with lower-level codes or if using MDM for level selection.
Also, Medicare has its own code (G2212) for prolonged office visits – using 99417 for Medicare patients will be denied.
Documentation: clearly record start/end times of prolonged services and the work done in that extra time (to justify medical necessity for going long).
99418 Prolonged Service (Inpatient/Obs)
Description: Each 15 min prolonged beyond highest inpatient/observation service.
New in 2023, analogous to 99417 for hospital settings. Use with 99223, 99233, 99236, 99255, etc., after their maximum time is exceeded.
Pitfalls:
Same principles as 99417 – ensure at least 15 min beyond the base code’s time and that time (not MDM) was the basis for the E/M level.
Medicare provides alternate codes (G0316, etc.) instead of 99418.
Document the additional time and tasks performed.
Many clinicians forget to bill prolonged services they’re entitled to, or attempt to bill them without hitting the required time – both scenarios can cause lost revenue or claim denials.
98000–98015 Telemedicine E/M (2025)
Description: New for 2025: E/M codes for synchronous telehealth visits.
98000-series codes cover real-time audio-video or audio-only visits for new and established patients (graded by MDM complexity similar to 99202–99215).
Created to replace using office-visit codes with a telehealth modifier.
2025 update: 17 new codes (e.g., 98004 = est. patient, straightforward MDM, 10 min+).
Pitfalls:
Payer adoption varies – CMS (Medicare) announced it will NOT cover these new codes in 2025 under current policy, so Medicare wants you to keep using 99202–99215 (with modifiers) for telehealth.
Private payers differ – confirm which payers require 98000-series vs. standard E/M.
Also note audio-only codes require “>10 minutes of medical discussion” per CPT – ensure call length is documented.
Until laws and payer policies catch up, telehealth coding in 2025 is tricky: use the new codes appropriately but be prepared to revert to office codes as needed for certain payers.
Detailed Analysis of Key E/M Codes
Office/Outpatient Visit Codes (99202–99215)
CPT 99214 – Established Patient Level 4 Office Visit
Description: Moderate-complexity visit for an established patient.
Requires a “medically appropriate” history/exam and moderate level of medical decision making (MDM), or 30 minutes of total time on the date of encounter.
Most frequently used E/M codes in all of medicine – Medicare paid for 98.5 million claims of 99214 in 2022.
Physicians often bill 99214 for routine follow-ups where multiple issues or medication management are addressed.
Why it’s frequently used:
Strikes a balance between complexity and efficiency.
Covers patients with chronic conditions or new problems that require moderate evaluation, without rising to the extreme level of 99215.
Reimburses significantly more than a level 3 (approximately vs on average).
Why it’s tricky:
High-value and common, it’s a magnet for auditing.
99214 was the #1 most-billed code to Medicare in recent data, and also one of the most error-prone.
Over 63% of improper payments on 99214 claims were due to incorrect coding (upcoding or downcoding).
Pitfalls:
Billing 99214 when the visit documentation only supports a level 3.
Insufficient detail can lead payers to downcode 99214 to 99213.
Forgetting to document all relevant components.
2025 updates: No specific CPT changes to 99214 itself in 2025.
Common Mistakes:
Upcoding due to assumed complexity.
Not linking the documentation to the level.
Undercoding 99214 as 99213 out of caution.
CPT 99213 – Established Patient Level 3 Office Visit
Description: Low-complexity established patient visit (straightforward MDM, or ~20 minutes of time).
In 2022 it was the second-most billed outpatient E/M (about 73.6 million Medicare claims) just behind 99214.
Involves routine follow-ups for stable chronic conditions or minor acute problems.
Why it’s frequently used: It covers a broad range of simple visits – many encounters don’t require the depth of 99214.
Why it can be tricky: The main challenge is distinguishing between a level 3 and level 4 service under the current guidelines.
Pitfalls:
Undercoding: A provider might habitually bill 99213 for brevity, even when their work actually met 99214 (losing reimbursement).
Overcoding: On the other hand, billing 99213 when only a nurse or tech performed a minimal service could be inappropriate.
2025 updates: No direct changes to 99213, but as with 99214, consider telehealth coding rules if the visit is virtual.
Common mistakes:
Assuming a standard level.
Lack of documentation for elements like a brief exam or history could lead reviewers to question if even 99213 requirements were met.
Using 99213 when a procedure or test was the main service and an E/M wasn’t truly significant.
CPT 99215 – Established Patient Level 5 Office Visit
Description: Reserved for the highest complexity outpatient visits.
Involves a medically appropriate history/exam and high-level MDM, or at least 40 minutes of total time spent.
Rarely used relative to other office codes (roughly ~5% of established patient visits historically).
Why it’s tricky: Justifying 99215 is challenging.
Requirements for high complexity MDM:
Extensive problems (e.g., one or more chronic illnesses with severe exacerbation or a new problem posing threat to life).
Extensive data (multiple tests, records, or consults reviewed).
and/or high risk (e.g., decision to escalate care/hospitalize, or severe drug therapy monitoring).
Time can be an easier criterion (≥40 min), but you must ensure your documented time is credible and includes only qualifying activities.
Error rates are high. One Medicare contractor audit (NGS in 2016) found 65% of 99215 claims lacked sufficient documentation and were downcoded or denied.
2025 updates: No new changes to 99215’s definition.
Common mistakes:
Coding 99215 without meeting the requirements
Not documenting time when it could justify 99215
CPT 99204 – New Patient Level 4 Office Visit
Description: The new-patient counterpart to 99214, indicating a moderate complexity visit for a patient who hasn’t been seen before (or in 3+ years).
The CPT descriptor requires moderate MDM or 45 minutes of total time.
According to CMS data, 99204 is the most -used new patient code, with 12.3 million allowed Medicare claims in 2022.
Why it’s frequently used: Even after the guideline changes, many new patient visits naturally fall into moderate complexity.
Why it’s tricky: The main challenge is ensuring the comprehensive work for a new patient is documented.
2025 updates: No specific changes to 99204.
Common mistakes:
Incomplete documentation for new patients.
Not clearly documenting all the problems addressed can make a level 4 look like a level 3.
Billing 99204 for very simple new visits (like a healthy patient with a single minor issue) is an error
CPT 99205 – New Patient Level 5 Office Visit
Description: The highest complexity new patient code (high MDM or 60+ minutes).
Comparatively rarely billed, as it’s reserved for initial visits that are extremely complex or lengthy.
Why it’s tricky: Documentation must be thorough and indicate high complexity. For new patients, this often means multiple extensive workups or consultations arranged on that first encounter, and usually consideration of high-risk management.
Common mistakes:
Overestimating complexity.
Not billing 99205 when appropriate.
Finally, ensure coordination with prolonged services: if you exceed 74 minutes of time, you should add 99417
Hospital Inpatient & Observation Codes (99221–99239)
Note: As of CPT 2023, inpatient and observation E/M codes have been merged – use 99221–99223 for initial hospital or observation care, 99231–99233 for subsequent visits, and 99234–99236 for same-day discharge admissions.
CPT 99223 – Initial Hospital Visit, Level 3 (High Complexity)
Description: Used for the first hospital encounter (admission) when the patient’s condition and workup are very complex.
Under CPT descriptors, it requires a comprehensive evaluation and high-complexity MDM (or around 75 minutes or more, if using time).
Clinicians use 99223 for critically ill or highly unstable patients on admission.
Why it’s tricky: Documentation burden is high.
One review found 78% of sampled 99223 claims were downcoded or denied because they didn’t meet criteria.
2025 updates: No direct changes to 99223.
Common mistakes:
Upcoding moderate admits as 99223.
Forgetting to update the exam or history from an ER note
CPT 99233 – Subsequent Hospital Visit, Level 3 (High Complexity)
Description: This is the highest level for daily follow-up visits on hospitalized patients. It signifies high complexity or unstable patient management on a given day.
Coding guidelines imply that 99233 should be reserved for days when the patient is unstable, deteriorating, or at high risk.
Why it’s tricky: Among hospitalists, 99233 is notoriously overused when not truly warranted.
One explicit piece of advice: “Bill the highest subsequent visit level – 99233 – only for patients with a deteriorating condition, backed up by your documentation”.
2025 Updates: None
Common Mistakes:
Lack of documentation of worsening status.
Insufficient history/exam on a high- level day
Copy-paste issues.
CPT 99232 – Subsequent Hospital Visit, Level 2 (Moderate Complexity)
Description: This code covers the majority of inpatient follow-ups – when a patient is improving or mildly to moderately ill and the visit involves a moderate level of decision-making.
Why it’s important: 99232 is the “bread and butter” daily hospital visit.
Documentation tips: Ensure your note each day includes interval changes and active management of problems.
Common pitfalls: Sometimes providers default to 99232 for all follow-ups, even on days that are really simple (which might be 99231) or very complex (should be 99233).
Hospital Discharge and Same-Day Codes (99234–99238)
These codes handle discharge day management and same-day admits/discharges.
Common mistake: forgetting to code the discharge service or using the wrong code when a patient is admitted and discharged on the same calendar day
Emergency Department Visit Codes (99281–99285)
CPT 99285 – Emergency Department Visit, Level 5
Description: This is the highest level ED visit for patients seen in the Emergency Department.
Not Distinguish new vs established patients and based on complexity
Why it’s tricky: One challenge is that ED codes historically required the “three key components” (history, exam, MDM).
MDM documentation is everything for 99285.
Usage: 99285 is actually very commonly used in EDs – about 40% of ED E/M services billed to Medicare in 2022.
Common Mistakes:
The biggest issue is incomplete documentation leading to downcoding.
ACEP notes that a poorly documented 99284 that gets downcoded to 99283 loses nearly 50% of the RVUs (and thus revenue).
CPT 99284 – Emergency Department Visit, Level 4
Description: This code represents moderate complexity in the ED.
The line between 99284 and 99285 can be thin; often it hinges on whether the physician’s decision-making had to address serious threats or just moderate concerns.
Common mistakes:
The most common error is under-documenting a 99284 such that it gets coded as 99283.
Another mistake is overcoding to 99285 when the case was actually moderate.
Consultation Codes (99242–99255)
CPT 99245 (Outpatient Consultation, Level 5) and 99255 (Inpatient Consultation, Level 5)
Description: Consultation codes are used when one physician (or qualified provider) requests another physician’s opinion or advice on a patient, and the consultant evaluates the patient and reports back.
Consult codes have unique rules (initiation from another provider, documentation requirements).
Common mistakes:
The classic error is billing a consult code without a documented request or report.
Many auditors will deny a consult code if the chart lacks a referring physician’s name/request or if it reads like a routine visit.
Another pitfall is using consult codes for Medicare
A related mistake is continuing to bill subsequent visits with consult codes.
Also, ensure you choose the correct level.
2025 updates: No further changes beyond the 2023 ones.
Prolonged Services Codes (99417 & 99418)
CPT 99417 – Prolonged Outpatient E/M Service (15 min increments)
Description: This is an add-on code introduced with the 2021 E/M overhaul.It’s used when an office or outpatient visit (either 99205 or 99215, or certain other high-level services like 99245) runs long beyond the typical time.
You can only use 99417 when you have already met the highest level code based on time and gone at least 15 minutes over.
Medicare does not use 99417 instead, Medicare created HCPCS code G2212.
If a visit doesn’t reach the time threshold for 99205/99215, you cannot use 99417 at all.
Common mistakes:
One error is billing 99417 with the wrong primary code.
Another mistake is counting time incorrectly
Documentation is another area of risk: You should document the total time spent and ideally break down what was done in that prolonged period.
CPT 99418 – Prolonged Inpatient/Observation E/M Service (15 min increments)
Description: Introduced in CPT 2023, 99418 is analogous to 99417 but for inpatient or observation settings (and also applies to other services like inpatient consults).
Each unit represents 15 minutes beyond the usual time of the primary service.
Medicare again doesn’t recognize 99418; instead, for 2023 onward, Medicare uses G0316
Common mistakes:
Same errors as 99417 – using it without truly exceeding the time threshold, or with the wrong primary code.
The time spent on a patient on a given day might include both floor time and unit/floor time.
And like with all prolonged codes, document well
Critical Care Services (99291, 99292)
CPT 99291 – Critical Care, First 30-74 Minutes
Description: This code is for physician care of a patient in a critical condition, where the physician is providing full attention to a single patient (or coordinating their care) for at least 30 minutes.
Critical care coding has strict requirements:
Time threshold: A minimum of 30 minutes actual clinician time must be devoted.
Exclusive attention: The physician cannot be providing services to any other patient during this time.
Qualifying activities: The time can include bedside care, reviewing labs/images, discussing with other professionals, and documenting – as long as all relate to that patient’s critical care.
Common mistakes:A key mistake is failing to document time. Without time, coders can’t assign 99291. Always chart “I spent X minutes in critical care for this patient.”
Another mistake is trying to use 99291 for a series of periodic checks that don’t sum to 30 min
Some providers also double-code incorrectly: You cannot bill both an E/M visit (like 99233 or 99285) on the same day as 99291 by the same provider for the same patient
### CPT 99292 – Each Additional 30 Minutes of Critical Care
This add-on code is used if critical care extends beyond 74 minutes. 99291 + 99292×1 for 75-104 minutes
The time should be non- consecutive sum of critical care activity throughout the day by one provider (or shared within a group if split/shared rules apply – that’s another complexity beyond scope here).
Telehealth E/M Codes (98000-Series in 2025)
CPT 98000–98015 – Telemedicine Evaluation & Management visits
Brand new in CPT 2025, this is a set of 17 codes dedicated to reporting outpatient E/M services conducted via telehealth.
-The introduction of these codes has created payer confusion.The AMA made them available starting Jan 2025, but Medicare announced it will NOT reimburse these new codes in 2025 due to statutory limitations. Common mistakes:
Early adopters might inadvertently use the wrong code for the modality
Another possible mistake is not meeting the time requirement – especially for audio-only, if you don’t actually have >10 minutes of discussion, you shouldn’t bill 98012-98015. In such cases, you might have to default to some other code or not bill if minimal.