The short version: E/M codes are the evaluation and management CPT codes that report office visits, and in the outpatient setting the ones to know are 99202 to 99205 for new patients and 99211 to 99215 for established patients. Since January 2021, the level is selected by either total time or medical decision making, not by history and exam.
A revenue officer does not need to code like a certified professional coder, but you do need to know why an E/M level survives an audit or collapses under one. Most behavioral health organizations bill E/M for psychiatric medication management, so the level a prescriber assigns, and whether the note supports it, drives both revenue and audit exposure. Here are ten E/M codes and concepts worth knowing.
99202 to 99205: new patient office visits
These four codes report office or outpatient visits for a patient who is new to the practice, meaning no professional service from the group or specialty in the prior three years. They run from 99202 (lowest) to 99205 (highest). Code 99201 was deleted in 2021, so a new patient office visit now starts at 99202. New patient levels require more work because there is no prior history to build on.
99211 to 99215: established patient office visits
These report visits for a patient the practice has seen within three years. They run from 99211 to 99215. For psychiatric prescribers, 99213 and 99214 carry most medication management volume, and the split between the two is the single most watched pattern in an E/M audit. Getting that distinction right, visit by visit, is where documentation discipline pays off.
99211: the minimal established visit
99211 is the one established code that may not require the presence of a physician or other qualified health professional. It covers a brief, low-complexity encounter such as a nursing check or a quick follow-up. Because it can be billed under incident-to rules, payers scrutinize it, so the note still needs to show a distinct, medically necessary service, not a routine touchpoint.
The 2021 rule: time or medical decision making
The biggest change revenue officers must internalize is that office E/M levels are now chosen one of two ways: total time on the date of the encounter, or medical decision making (MDM). History and exam are still performed and documented when clinically relevant, but they no longer drive the code. A note that reads like a thorough exam but shows little time and low MDM will not hold a high level.
How total time is counted
Time now means total practitioner time on the date of the encounter, both face-to-face and non-face-to-face, including chart review, ordering, and documentation. The ranges are fixed: 99202 is 15 to 29 minutes, 99203 is 30 to 44, 99204 is 45 to 59, and 99205 is 60 to 74. For established visits, 99212 is 10 to 19 minutes, 99213 is 20 to 29, 99214 is 30 to 39, and 99215 is 40 to 54. A time-based claim needs a total-time statement in the note.
The three elements of medical decision making
MDM is built from three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications or morbidity from patient management. The level (straightforward, low, moderate, or high) is set by meeting two of the three. In psychiatry, high-risk management such as controlled substance prescribing or suicidality assessment often supports moderate to high MDM, but only if the note spells it out.
Prolonged services: 99417 and G2212
When a visit runs past the top time range using the time method, prolonged services add-on code 99417 reports each additional 15 minutes with 99205 or 99215. Medicare does not recognize 99417 and instead uses HCPCS code G2212, which counts time differently. Knowing which add-on a payer accepts prevents denials and missed revenue on long visits.
E/M with psychotherapy: 90833, 90836, 90838
When a prescriber provides both a medication management visit and psychotherapy in the same session, the psychotherapy is reported with an add-on code alongside the E/M: 90833 for about 30 minutes, 90836 for about 45, and 90838 for about 60. The E/M level here is chosen by MDM only, not time, because the therapy time is billed under its own add-on code. This pairing is common in behavioral health and a frequent source of coding error.
Telehealth E/M and modifiers
Behavioral health delivers a large share of visits by telehealth, and those visits generally use the same office E/M codes with an appropriate place-of-service code and a telehealth modifier such as 95 for synchronous audio-video. Payment parity, audio-only rules, and place-of-service requirements have shifted repeatedly and vary by payer and by Medicare policy, so confirm the current rules for each date of service.
Downcoding and upcoding risk
Upcoding is reporting a level higher than the documentation supports, which creates overpayment and False Claims Act exposure. Downcoding is reporting lower than the work supports, which quietly leaks revenue and skews your data. The fix is not aiming for a target level; it is making the note match the time or MDM actually delivered.
How to get this right
Give prescribers a shared, plain-language reference for the time ranges and the MDM grid, then monitor your E/M distribution against specialty benchmarks so outliers surface early. Audit a small sample of charts each month and read the note against the level billed: does a time-based claim state total time, and does an MDM-based claim show two of the three elements? Treat telehealth documentation, add-on psychotherapy codes, and 99211 as their own review categories, because each carries a distinct risk. The goal is consistency between what happened, what the note says, and what the claim reports.
How Adentris helps
Adentris is an AI platform for revenue integrity and documentation compliance built for behavioral health and substance use disorder programs, and it works on top of the EHR you already use through API or HL7 where available, such as Alleva, Pimsy, Kipu, Epic, or Athenahealth, or a secure web agent otherwise, with no rip-and-replace. It reviews clinical notes in real time and flags missing or weak elements before the claim is submitted, from medical necessity to signature timing, and drafts the correction for the clinician to accept, so a psychiatric E/M note actually supports the level being billed. Compliance leaders get a live view of documentation risk across every site and program, the platform pairs review with an appeals and denials module, and it is HIPAA compliant and SOC 2 certified with 42 CFR Part 2 controls and BAAs in place. To see it on your own charts, book a 30-minute call with our team.
Related reading
- 10 Key Insights on CPT 97153 for Maximizing Revenue in ABA Therapy
- 9 Essential Strategies for Effective Medical Chart Auditing
- 10 Revenue Cycle Management Solutions to Boost Profitability
Frequently asked questions
What are E/M codes?
E/M codes are the evaluation and management CPT codes used to report office and outpatient visits and other patient encounters. In the outpatient setting the core codes are 99202 to 99205 for new patients and 99211 to 99215 for established patients. Since 2021, the level is selected by total time on the date of service or by medical decision making.
What changed about E/M coding in 2021?
Beginning in January 2021, office and outpatient E/M levels are chosen by either total time or medical decision making, and history and exam no longer determine the code. Code 99201 was also deleted, so new patient visits start at 99202. History and exam are still documented when clinically relevant, but they do not set the level.
How do I know whether to bill by time or by MDM?
Pick whichever method the visit best supports and whichever the note documents. Bill by time when the encounter is long relative to its complexity and the note states total time on the date of service. Bill by MDM when the clinical complexity is high, and make sure the note shows two of the three MDM elements.
Why is the 99213 versus 99214 split so important?
Those two established patient codes carry most psychiatric medication management volume, so their ratio is what auditors examine first. A pattern skewed toward 99214 without supporting time or MDM signals upcoding, while a pattern stuck at 99213 signals lost revenue. The right ratio is simply the one your documentation actually supports.
