Evaluation and Management Services

Introduction

The purpose of this document is to outline Workforce Safety & Insurance’s (WSI) policy regarding the documentation and billing of evaluation and management (E/M) services.

Policy 

WSI has adopted both the American Medical Association (AMA) 2021 and 2023 CPT® Evaluation and Management (E/M) Code and Guideline Changes for auditing of the following evaluation and management services:

• Office and Outpatient Services (99202-99215)
• Prolonged Services (99358, 99359, 99417, 99418)
• Hospital Inpatient and Observations Care Services (99221-99223; 99231-99239)
• Emergency Department Services (99281-99285)
• Nursing Facility Services (99304-99310, 99315, 99316)
• Home or Residence Services (99341, 99342, 99344, 99345, 99347-99350) 

WSI will audit all E/M service medical records for authentic documentation of the following:

• Medically appropriate history and examination
• Medical decision making (MDM) or total time for physician or other qualified health care professional (QHP) for the E/M services on the date of the encounter
• Medical necessity 

WSI will reimburse the appropriate level of service based on the risk and complexity of the service rendered as supported by the medical documentation. A billed service not supported by authentic medical documentation will result in a denial. See Falsified Medical Records Policy for clarification on criteria for authentic medical documentation. 

For detailed guidance on WSI’s code and guideline changes, see Appendix: Evaluation and Management Services

References 

American Medical Association (AMA) CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf, last accessed 6/19/2025. 

American Medical Association (AMA) CPT® Evaluation and Management (E/M) Code and Guideline Changes effective January 1, 2023. Retrieved from https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf, last accessed 6/19/2025. 

American Medical Association (AMA) CPT® 2023 Professional Edition

Appendix

Evaluation and Management Services:

The following guidelines outline the information Workforce Safety & Insurance (WSI) reviews when auditing medical documentation for Office and Other Outpatient Evaluation and Management (E/M) Services (99202-99215) and Prolonged Services (99354-99359, 99417). WSI structured these guidelines based on the American Medical Association (AMA) 2021 CPT® Evaluation and Management (E/M) Office or Other Outpatient Code and Guideline Changes. 

Evaluation and Management (E/M) office or other outpatient services may be reported based on one of the following:

Medical Decision Making (MDM)
MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. MDM is defined by the following three elements:

• Number and Complexity of Problems Addressed
• Amount and/or Complexity of Data to be Reviewed and Analyzed
• Risk of Complications and/or Morbidity or Mortality of Patient Management 

Total Time
Total time on the date of encounter personally spent by the physician and/or qualified health care professional (QHP) for E/M services. • 

• Total Time for face-to-face and non-face-to-face services must be documented in the medical record. For activities included in time calculation, see 2023 American Medical Association (AMA) CPT® E/M descriptors and guidelines
• Documentation should include information identifying how the time was spent and be unique to the patient and the encounter 

Prolonged Services
A prolonged service is to be reported per the AMA guidelines.

• +99417 may be reported when total time on the date of the encounter is used as the basis for the selected office or other outpatient service and the minimum time requirement to report the highest level of service has been exceeded by 15 minutes
• +99418 may be reported when total time on the date of the encounter is used as the basis for the selected inpatient or observation service and the minimum time requirement to report the highest level of service has been exceeded by 15 minutes.
• 99358, 99359 is to be utilized for prolonged services on a date other than the date of the face-to-face encounter
• Clinical staff time and time spent performing separately reported services is not included in the total time for the E/M and prolonged services time 

Services Reported Separately
Any specifically identifiable procedure or service, i.e., identified with a specific CPT code, performed on the date of the E/M services may be reported separately.

• The actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when billed separately