This page addresses follow-up questions and additional information pertinent to our webinar
E/M Services FAQs: From the Office to the ICU and Everything in Between.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.
Q: What if a critical care service crosses a midnight – how would that time be calculated and reported?
A: Both CPT and CMS agree that for a single MD or NPP providing a continuous critical care service that extends beyond a midnight, the total units of continuous critical care time can be reported. However, any disruption in the service does create a new initial service. Although not explicitly stated, the inference is that the DOS for billing the critical care codes would be the date the continuous service was initiated.
Q: Does the independent history need to be obtained by the provider in person?
A: Per CPT (2025) this does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information. For example, a nurse can take a required confirmatory history directly from a patient’s spouse and document this in the EMR for the provider to review.
Q: What codes would we use for a provider who sometimes asks a patient to meet her at the local ED instead of her office?
A: Per CMS, in this situation, when the patient is not registered in the ED, then the office visit/outpatient codes should be used.
Looking for additional information on this topic?
Meet the Presenter: Carol Paton, MSc, PG Cert., CPC, CPMA
Carol brings over 20 years of industry experience to her role as a Senior Coding Educator at Haugen Consulting Group. With a background in nursing, Carol brings a unique perspective to coding education, allowing her to communicate effectively with both coders and providers to ensure a high-quality learning experience. A proven self-starter and valuable team member, Carol excels at motivating and developing others while building positive relationships across teams and departments. Her career spans several large specialty health systems, where she has served as a coding auditor and educator, delivering targeted education across various service lines.
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