Recent updates to E/M billing and coding

CMS revised an MLN Booklet on evaluation and management (E/M) services to clarify billing and coding requirements for critical care scenarios, hospital outpatient clinic visits, telehealth services, and more.

CMS added information on Healthcare Common Procedure Coding System (HCPCS) code G2211, which is used to capture the complexity of an office or outpatient (O/O) E/M visit. As of January 1, 2025, facilities can bill this add-on code when they report Current Procedural Terminology (CPT®) codes 99202–99205 or 99211–99215 with modifier -25 to describe services furnished by the same practitioner on the same day as one of the following:

• Annual wellness visit
• Vaccine administration
• Part B preventive service (including the initial preventive physical examination furnished in the O/O setting)

The agency also added guidance on the proper use of modifier -25, which is used to report a significant, separately identifiable E/M service provided by the same physician on the same date. Along with including a detailed definition of a significant, separately identifiable E/M service, CMS clarified payment for intravitreal eye injections performed on the same date as an O/O E/M visit.

The booklet now also includes more information on CPT codes 99291 and 99292, which are used to report critical care services. CMS added several if-then scenarios for both codes, as well as a critical care billing table that includes specific instructions for a variety of situations. For example, if multiple providers from different specialties furnish critical care services to a patient on the same day, each provider may bill CPT codes 99291 and 99292, if applicable. However, the services must be distinct and not duplicative.

CMS provided additional instructions on billing HCPCS code G0463 to report a hospital outpatient clinic visit for assessing and managing a patient. Facilities can bill G0463 on its own, or they can bill it as a visit code in addition to a procedure code. Non-excepted off-campus provider-based departments (PBD) should use modifier -PN to report services provided at their facility, and excepted off-campus PBDs should use modifier -PO.

Lastly, CMS added information on recent telehealth updates and upcoming flexibility expirations. For most telehealth services, the statutory limitations in place prior to the COVID-19 public health emergency will take effect again on October 1, 2025. As of January 1, 2025, an interactive telecommunications system may include two-way, real-time, audio-only technology for any Medicare telehealth service furnished to a patient in their home if the following criteria are met:

• The distant site physician/practitioner is technically capable of using an interactive telecommunications system
• The patient isn’t capable of or does not consent to using video technology

For dates of service in 2025, organizations are to continue billing telehealth services with the same place of service (POS) code that they would bill for an in-person visit. Facilities can use POS code 10 if the patient is in their home when the telehealth services are rendered or POS code 02 if they are not. POS code 10 will continue to be paid at the non-facility rate.

Revenue integrity professionals can view the updated E/M guidance for a complete list of codes added to the Medicare telehealth services list for 2025, as well as CMS’ guidance on telehealth and remote patient monitoring for additional information.

Editor's note: This article originally appeared in Revenue Integrity Insider, NAHRI's weekly e-newsletter.