Evaluation and Management (E/M) coding can be complex. To provide clarity, here’s a summary of three questions addressed during the American Medical Association’s 2025 CPT & RBRVS Symposium:
1. If a patient has 15 diagnoses and takes 20 medications, but none of the conditions are specifically life-threatening, is it appropriate to report CPT code 99215?
For a patient with numerous conditions and medications but no life-threatening issues, CPT code 99215 is generally not appropriate. The number and complexity of problems addressed during an encounter help determine the correct level of service. Comorbidities and underlying diseases are only considered if they directly impact the care provided by increasing the complexity of data review, patient management, or risk of complications.
To qualify as a high level of Medical Decision Making (MDM) under the “problems addressed” element, the patient must have:
- One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; OR
- An acute or chronic illness or injury that poses a threat to life or bodily function.
Simply “stacking” multiple non-life-threatening problems does not elevate the MDM level.
2. Does prescribing antibiotics for an acute condition in the ED count as prescription drug management?
Yes, prescribing antibiotics or any other medication for an acute condition in the Emergency Department (ED) qualifies as Prescription Drug Management. This reflects the physician’s decision-making process, including assessing the condition and determining the appropriate treatment. Importantly, this applies to management across all settings—office, ED, or inpatient.
3. What does “near term” mean in the E/M Table of Risk?
The term “near term,” as used in the AMA’s definition of acute or chronic conditions posing a threat to life or bodily function, is not explicitly defined in CPT guidelines. Instead, it relies on the clinical judgment of the treating physician or qualified healthcare professional (QHP).
The concept focuses on risks that might lead to significant complications, morbidity, or mortality within a relatively short timeframe if left untreated. For example, untreated osteoarthritis or hypertension may pose long-term risks but would not typically be classified as high-risk under this definition. The goal is to differentiate immediate, actionable risks from potential, long-term consequences.
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