What a bill represents
A patient visits for diabetes care. You assess control, decide what to do with medication, and arrange follow-up. Your note explains that care. A claim tells the insurer which service you provided and why it was needed. The insurer then applies its coverage and payment rules.
Three different questions are involved: Was the care appropriate? Which code describes it? Will this plan pay for it? A code cannot make unnecessary care necessary, and a correct code does not guarantee payment.
| Term | Plain meaning |
|---|---|
| CPT / HCPCS | Service codes. CPT is Current Procedural Terminology; HCPCS is the Healthcare Common Procedure Coding System. Examples: 99214 for an established-patient office service and G0439 for a subsequent Medicare wellness visit. |
| ICD-10-CM | Diagnosis codes that describe the condition, symptom, or other reason for care. |
| E/M | Evaluation and management: the clinical work of evaluating a problem and deciding how to manage it. |
| Modifier | Extra information attached to a code. Modifier 25 explains that a qualifying separate E/M occurred alongside another service. |
| QHP | A qualified health care professional who can independently report the relevant professional service, such as an eligible nurse practitioner or physician assistant. |
| RVU | A relative value unit. Work RVUs value professional work; total RVUs also include practice expense and malpractice. They are not dollars or profit. |
Choose the visit family
Before deciding how complex a visit was, decide what kind of service it was. A wellness visit, a problem visit, and follow-up after a hospital discharge have different requirements.
| Work performed | Starting point | What distinguishes it |
|---|---|---|
| Evaluate or manage a problem | Office E/M: 99202–99205 new; 99212–99215 established | Select the level by decision-making or qualifying time. |
| Evaluate a problem by video or telephone | Telehealth E/M: code family depends on the payer and modality | Distinguish a full visit from a brief check-in; document how the encounter occurred. |
| Routine preventive physical | 99381–99387 new; 99391–99397 established | Age-specific preventive medicine service; different from a Medicare AWV. |
| Preoperative medical evaluation requested by a surgeon | Consultation 99242–99245 if the payer accepts it and consultation requirements are met; otherwise office E/M | Document the request, medical assessment, and report back. “Preop” alone does not establish 99244. |
| Medicare prevention planning | G0438 first annual wellness visit; G0439 subsequent | A defined prevention service, not a routine head-to-toe physical. |
| Welcome to Medicare | G0402 | The initial preventive physical examination, available in the first 12 months of Part B enrollment. |
| Transition home after a qualifying facility stay | 99495 or 99496 | A service spanning the transition, with contact, timing, and coordination requirements. |
| Perform a procedure | The procedure code | A separate E/M is an additional decision, not an automatic companion. |
For office E/M, “new” generally means no professional service from you or another clinician of the same specialty and subspecialty in the same group within the past three years. Being new to your personal schedule is not enough. 99211 is a distinct low-level established-patient service with its own supervision and billing requirements; it is not a charge for every staff interaction.
Rule source: CMS E/M guide. Use the CMS wellness checklist for the full preventive-service elements and eligibility.
Preventive physicals: 99395 and related codes
A healthy 32-year-old established patient comes for a routine physical. You perform the appropriate preventive history and examination, assess risks, discuss prevention, and make a screening and immunization plan. 99395 describes this preventive medicine service. It belongs to a different family from problem-oriented office visits and Medicare annual wellness visits.
| Age | New patient | Established patient |
|---|---|---|
| 18–39 years | 99385 | 99395 |
| 40–64 years | 99386 | 99396 |
| 65 years and older | 99387 | 99397 |
The pediatric counterparts are 99381–99384 and 99391–99394, with their own age bands. A patient already established with the same specialty and subspecialty in your group does not become “new” because this is their first physical with you. Preventive codes are not selected by the 99202–99215 MDM or time thresholds.
AAFP: preventive medicine code selection; AAFP: adult preventive code table.
Document the prevention work
Record an age- and risk-appropriate history and examination; relevant personal, family, and social history; risk assessment; counseling; and the screening, vaccination, and follow-up plan. State what is due, what was offered or ordered, and what the patient deferred. “Annual physical, normal” leaves the service unclear. There is no requirement to order a standard laboratory panel for every physical.
Documentation outline: Preventive visit for [age]-year-old [new/established] patient. History and risk factors: [findings]. Age- and risk-appropriate examination: [findings]. Counseling: [topics and agreed actions]. Screening and immunizations: [due/completed/ordered/deferred, with reasons]. Follow-up: [plan]. Document any separate problem assessment and management distinctly.
For a general adult examination, Z00.00 describes an encounter without abnormal findings; Z00.01 describes one with abnormal findings, with an additional code identifying the finding. Follow the ICD-10-CM definition: an abnormal finding is a newly identified condition or a change in severity of a chronic condition. A stable diagnosis on the problem list does not automatically require Z00.01, and Z00.01 does not itself establish a separate problem E/M.
AAFP: preventive documentation components (use current diagnosis codes, not that article's historical ICD-9 examples); FY 2026 ICD-10-CM guidelines, Section IV.P.
A physical plus hypertension management
Fictional coding example. During an established 35-year-old patient's preventive visit, you also evaluate hypertension that is persistently above goal. You review the trend, assess adherence and adverse effects, increase prescription treatment, and arrange monitoring. That significant additional work is documented separately from prevention.
The preventive service supports 99395. The separate poorly controlled chronic illness supplies moderate problems, and prescription management supplies moderate risk: 99214-25 may also be reportable. Modifier 25 goes on the problem E/M. If selecting that E/M by time, exclude the preventive-service time.
What if you only review the medication list and record an acceptable blood pressure?
Those facts alone do not demonstrate a significant additional problem service. Do not automatically add 99213 or 99214 to every physical. Conversely, an actual separate assessment and prescription decision can qualify even when treatment is continued; a medication change is not mandatory.
Explain the distinction before providing additional care when feasible: the preventive benefit may cover the physical while the plan applies a copayment or deductible to the problem visit.
AAFP: combined preventive and problem visits; AMA: MDM elements.
Check the benefit and the work values
Traditional Medicare does not cover a routine physical under 99395–99397. Its G0402 Welcome to Medicare service and G0438/G0439 AWVs have distinct eligibility and required elements. Do not substitute an AWV code for a physical unless you actually perform the AWV. Some Medicare Advantage plans offer an additional physical benefit; verify that product's coverage and rules before combining services.
For commercial or Medicaid coverage, check eligibility, network, and frequency rules. An “annual” benefit may follow a calendar-year or rolling interval. Tests and vaccines can have their own coverage and reporting rules; the physical does not make every associated service free.
In CMS's July 2026 reference file, work RVUs are 1.75 for 99395, 1.90 for 99396, and 2.00 for 99397. The corresponding new-patient codes carry 1.92, 2.33, and 2.50. These codes have Medicare status N (noncovered); published work values do not establish Medicare payment or your employer's productivity credit.
AAFP: AWVs versus physicals; CMS RVU26C, updated June 30, 2026. Reviewed September 17, 2026.
Learn medical decision-making
Medical decision-making (MDM) describes the complexity of the problems you addressed, the information you analyzed, and your management decisions. It has three elements: problems, data, and risk. The overall level requires two of the three elements to meet or exceed that level.
Count the conditions assessed and the management decisions made today. The examples below show how a decision to continue treatment can support the risk element.
| Element | Lower complexity | Moderate examples | High examples |
|---|---|---|---|
| Problems addressed | One stable chronic illness or an uncomplicated acute illness | Two stable chronic illnesses; a chronic illness worsening or causing treatment side effects; an undiagnosed problem with uncertain prognosis | A condition threatening life or bodily function, or a severe chronic-disease exacerbation |
| Data analyzed | Limited qualifying test or record review | A qualifying combination of three data items, an eligible independent interpretation, or an eligible management discussion | Meet two of the three data categories described below |
| Management risk | Low-risk management | Prescription drug management, when actually performed | A decision about hospitalization or drug therapy requiring intensive monitoring for toxicity |
The full definitions control: AMA E/M guidelines and MDM table. A single item in the high column does not establish high MDM.
One stable illness, then two
An established patient has hypertension at the agreed goal. You review home readings and tolerance, decide to continue lisinopril, and set follow-up. No qualifying data raises the data element.
The problem element is low; prescription management makes risk moderate. Only one element is moderate, so the visit supports low MDM: 99213.
Now suppose you also assess stable hyperlipidemia and make a documented decision to continue its prescription treatment. The two stable illnesses make the problem element moderate. With moderate prescription-management risk, the visit supports 99214.
Continuing treatment after assessing benefit, control, and tolerance can be prescription management. The medication primer covers how to assess those benefits and harms.
How to think about data without inflating it
Count distinct qualifying work. A panel is not one data item per analyte. Ordering a test and reviewing its result as part of the same work does not turn it into two unique tests. An independent interpretation is different from reading someone else's report, and you cannot also count an interpretation you separately report toward that MDM element. An external discussion requires an actual exchange; sending a referral is not that discussion.
For moderate data, learn three categories: qualifying records/tests/historian; independent interpretation; and management or test-interpretation discussion. An independent historian supplies necessary history because the patient cannot provide a complete or reliable account—not simply because another person is in the room.
AMA MDM explanations and data definitions.
Three data items, counted explicitly
Fictional coding example. You assess one stable chronic illness: hypertension. You review home readings and tolerance and decide to continue its prescription treatment. To make that decision, you also perform this necessary work:
- External note: review the relevant cardiology consultation from a distinct outside group. One unique external source.
- Test: order a basic metabolic panel for indicated medication monitoring. One unique test; its component analytes do not count separately.
- Independent historian: obtain necessary medication and symptom history from the daughter because cognitive impairment prevents a reliable complete account from the patient. One historian element.
Those three items meet moderate data through category 1. Prescription management supplies moderate risk, so two elements support moderate MDM and 99214 for this established patient, even though the hypertension problem element is low.
What if the daughter is only present for company?
Then her presence does not supply the historian element. The external note and panel alone do not reach the three-item category-1 threshold. With one stable illness, no other qualifying data, and the prescription decision described, only risk is moderate: this supports 99213 by MDM. Qualifying time, if used instead, is a separate route.
AMA: category-1 data and historian definitions; data-counting FAQs. Count work clinically needed and actually performed; the example is not an instruction to obtain extra items for a code.
Use time correctly
Office E/M has an alternative to MDM: total qualifying physician/QHP time on the date of service. It can include preparation, evaluation, counseling, orders, and documentation. Staff time and time for separately reported services do not belong in that total.
| MDM level | New patient | Minimum time | Established patient | Minimum time |
|---|---|---|---|---|
| Straightforward | 99202 | 15 min | 99212 | 10 min |
| Low | 99203 | 30 min | 99213 | 20 min |
| Moderate | 99204 | 45 min | 99214 | 30 min |
| High | 99205 | 60 min | 99215 | 40 min |
A 36-minute encounter with a procedure
You spend 36 minutes in total, including 10 minutes performing a separately billed procedure. Qualifying E/M time is 26 minutes. For an established patient, that supports 99213 by time.
If the separate E/M instead meets moderate MDM, it can support 99214 by MDM. The procedure does not automatically lower the level. Either way, confirm that the E/M is significant and separately identifiable.
Medicare uses G2212 for qualifying prolonged office services. With a time-selected 99215, the first unit starts at 69 minutes; with 99205, at 89 minutes. A 60-minute established visit is still 99215 without G2212. Commercial plans may use different prolonged-service rules.
CMS E/M and prolonged-service guidance. The thresholds above refer to eligible E/M time, after exclusions.
Preop evaluations and consultations
A surgeon asks you to evaluate a patient's medical conditions before an operation. A primary care physician can report an outpatient consultation, including 99244, when the service qualifies and the patient's payer recognizes consultation codes. These codes can apply to your existing patients as well as new patients. A scheduled “preop clearance” appointment does not automatically qualify.
Establish the consultation: record who requested your opinion and the medical question, perform and document the assessment, and send your findings and recommendations back in a written report. A transfer of ongoing care or a patient-initiated visit alone does not meet that definition. The report should explain risk and recommendations rather than merely say “cleared.”
AAFP: preoperative evaluation billing supports the consultation pathway; its older code ranges and history/exam leveling discussion predate the current rules. See the AMA consultation guidelines for the revised definition and requirements.
Check the payer, then select the level
Traditional Medicare does not pay 99242–99245. For an office preop evaluation, select the supported new-patient 99202–99205 or established-patient 99212–99215 instead. Check the specific Medicare Advantage, Medicaid, or commercial plan's policy; commercial insurance does not guarantee consultation coverage. UnitedHealthcare's commercial policy, for example, does not reimburse these consultation codes.
CMS E/M guide, consultation services; UnitedHealthcare commercial consultation policy. The coverage page explains the office's payer checks.
| Code | MDM | Minimum time, if using time | 2026 work RVUs |
|---|---|---|---|
99242 | Straightforward | 20 minutes | 1.08 |
99243 | Low | 30 minutes | 1.80 |
99244 | Moderate | 40 minutes | 2.69 |
99245 | High | 55 minutes | 3.75 |
99244 requires moderate MDM or at least 40 qualifying minutes; both are not required. When using time, exclude staff time, work on other dates, and separately reported services. When using MDM, two of its three elements must reach the selected level. The planned operation alone does not establish moderate or high MDM.
AAFP: consultation MDM and time thresholds; AAFP: MDM and qualifying time. Work RVUs: CMS RVU26C, July 2026 non-QP file, updated June 30. CMS lists these consultation codes with status I (not valid for Medicare payment); listing RVUs does not make them payable by Medicare.
What the higher wRVU claim means
Using that same CMS file, 99244 carries 2.69 work RVUs versus 1.92 for 99214: a difference of 0.77, or about 40%. Compared with a new-patient 99204 at 2.60, the difference is only 0.09. An established-patient 99215 carries 2.80 and can be supported by 40 qualifying minutes when office E/M coding applies. Consultation coding is therefore not always the higher-wRVU route.
Choose the service family and level that describe the encounter under the payer's rules. These are work values, not payment amounts: the payer contract determines reimbursement, and your employment agreement determines which fee-schedule year and codes receive productivity credit.
One preop evaluation, two payer pathways
Fictional coding example. A surgeon requests your medical assessment before knee replacement. You assess hypertension and diabetes, both stable at their individualized goals, and make documented prescription-management decisions with a perioperative medication plan. You send the surgeon your written assessment and recommendations. Qualifying physician time is 28 minutes.
Two addressed stable illnesses supply moderate problems; prescription management supplies moderate risk. With the consultation requirements met and a payer that accepts consultations, this supports 99244 by MDM despite taking less than 40 minutes. For traditional Medicare, the same work supports 99214 by MDM if the patient is established.
What if qualifying time were 40 minutes?
For an established patient whose payer requires office E/M coding, 40 qualifying minutes can support 99215 by time, even with moderate MDM. For an eligible consultation, 40 minutes can support 99244. Apply the chosen family's criteria; do not mechanically convert 99244 into 99214.
Make the request and report visible
Preoperative medical evaluation requested by Dr. [name] for [procedure/date], addressing [specific medical question]. Relevant findings and condition status: [actual findings]. Assessment and recommendations: [risk assessment, medication decisions, any needed optimization, and follow-up]. Written report sent to Dr. [name] on [date]. If selecting by time: [actual qualifying minutes] personally spent on the encounter date, with separately reported services excluded.
This is a documentation outline; fill it with the care actually provided. For an encounter solely for preoperative evaluation, list the appropriate Z01.81- diagnosis first—often Z01.818 for other preprocedural examination—then the condition prompting surgery and relevant additional findings or conditions. The diagnosis code does not establish the E/M level.
FY 2026 ICD-10-CM guidelines, Section IV.M; AAFP: preprocedural diagnosis selection. Reviewed September 17, 2026.
Video and audio-only visits
A scheduled video appointment and a telephone appointment can both support an E/M service. First identify the payer's accepted code family, then apply its requirements to the actual encounter. The tables below describe synchronous visits: clinician and patient communicating in real time.
Start with the payer
Traditional Medicare: use eligible office E/M codes, generally 99202–99205 for new patients or 99212–99215 for established patients. Medicare does not recognize 98000–98015 for payment. For ordinary professional office E/M claims, Medicare does not require modifier 95 for video; append 93 for audio-only. Other billing settings have their own rules.
Commercial, Medicare Advantage, and Medicaid: confirm the plan's policy. Some accept the telemedicine codes below; others require office E/M codes with their specified modifiers. Do not label the newer codes as universally accepted “commercial” codes.
For Medicare audio-only visits at home, document that you could provide video but the patient could not use it or did not consent to video. Telephone access alone does not establish eligibility.
AAFP: payer-specific telehealth coding and modifiers.
Medicare's general location flexibilities, including home-based audio-only coverage, currently extend through December 31, 2027. For professional telehealth claims, use the patient's location: POS 10 at home or POS 02 elsewhere. Confirm the service is on the current Medicare telehealth list. RHCs and FQHCs follow separate payment rules, including G2025 for qualifying non-behavioral telehealth through that date.
CMS telehealth FAQ, updated February 26, 2026; CMS current telehealth service list. Coverage rules reviewed September 17, 2026; recheck for the date of service.
Audio-video: 98000–98007
| MDM | New patient: code / minimum minutes | Established: code / minimum minutes |
|---|---|---|
| Straightforward | 98000 / 15 | 98004 / 10 |
| Low | 98001 / 30 | 98005 / 20 |
| Moderate | 98002 / 45 | 98006 / 30 |
| High | 98003 / 60 | 98007 / 40 |
Audio-only: 98008–98015
| MDM | New patient: code / minimum minutes | Established: code / minimum minutes |
|---|---|---|
| Straightforward | 98008 / 15 | 98012 / more than 10 |
| Low | 98009 / 30 | 98013 / 20 |
| Moderate | 98010 / 45 | 98014 / 30 |
| High | 98011 / 60 | 98015 / 40 |
Select by MDM or qualifying total clinician time on the service date. For 98008–98015, more than 10 minutes of medical discussion is required even with MDM selection; record discussion time separately from total time. This threshold belongs to that code family, not Medicare's office E/M codes. The 98000–98015 codes already identify modality; CPT does not call for modifiers 95/93 on them.
AAP: telemedicine code tables and time requirements, pages 5 and 8–9. See qualifying time for which activities count.
Document the encounter
Real-time [video/audio-only] visit. Patient identity and location: [verified details]; clinician location: [location]. Participants: [names/roles]. Telehealth consent: [document according to applicable requirements]. If audio-only: [actual reason video was not used; clinician video capability when required]. Relevant history, obtainable examination findings, and limitations: [findings]. Assessment, treatment decisions, and follow-up: [actual care]. Medical discussion: [minutes, when required]. If coding by time: [total qualifying clinician minutes today], excluding separately billed work.
Record what you could assess remotely and any need for in-person evaluation. If video fails, document the portions completed by each modality and apply the payer's coding instructions. Do not turn an unperformed examination into normal findings through a template.
One follow-up, different telehealth codes
Fictional coding example. An established patient at home has hypertension and hyperlipidemia, both assessed as stable. You review monitoring, assess tolerance, and make documented decisions to continue both prescriptions. Two stable illnesses plus prescription management support moderate MDM.
If delivered by video, a payer accepting the telemedicine family may accept 98006; traditional Medicare uses 99214 with POS 10. If instead delivered by audio-only with 18 minutes of medical discussion, the corresponding codes may be 98014 or Medicare 99214-93 with POS 10, provided its audio-only eligibility rules are met. Thirty minutes is not required when these levels are supported by MDM.
What about a brief call or portal message?
These have separate rules. 98016 describes a qualifying established-patient virtual check-in with 5–10 minutes of medical discussion. It must not arise from a related E/M in the preceding seven days or lead to an E/M or procedure within 24 hours or the soonest available appointment. Portal E/M codes 99421–99423 cover qualifying patient-initiated online work over seven days. Neither is an automatic charge for routine results or scheduling messages. The old telephone codes 99441–99443 were deleted in 2025.
Write the reasoning
Record the reason for care, relevant findings, assessment, management, and follow-up so that another clinician can understand the decision and a reviewer can see what supports the service. Use history and examination appropriate to the problem; a longer template does not create a higher level.
Make continuation a visible decision
Too ambiguous: “HTN, HLD. Refill meds.”
Home BP log remains at the agreed goal; no dizziness or medication intolerance. Continue lisinopril. Hyperlipidemia is controlled on the current statin; no new muscle symptoms. Continue atorvastatin. Monitoring is current; return in six months, sooner for new symptoms or readings outside the agreed range.
Both chronic illnesses are assessed and both prescription decisions are explicit. This illustrates moderate problems plus moderate risk. Use the patient's actual findings, drugs, and follow-up plan.
When coding by time, a clear statement might be: “Total physician time today: 36 minutes for record review, evaluation, counseling, orders, and documentation; separately billed procedure time excluded.” Record the actual time spent.
Separate same-day services
A procedure includes the ordinary evaluation needed to perform it. A preventive visit includes its required prevention work. You may separately report a problem E/M when you provide a significant, separately identifiable service beyond that work. Modifier 25 belongs on the E/M.
A different diagnosis can make the separation easier to see, but it is not required. Conversely, two diagnoses do not prove that two services occurred. Ask what distinct assessment and management would remain if you removed the procedure's usual work.
Wellness visit plus diabetes care
You complete an eligible Medicare annual wellness visit (AWV). You also assess diabetes above the individualized goal, change prescription treatment after reviewing relevant risks, and arrange monitoring.
The AWV and a separate problem E/M may both be reportable. Document the wellness elements and the diabetes assessment/plan distinctly. Select the E/M from its own MDM or time, excluding wellness work; append modifier 25.
The wellness visit covers prevention planning. Evaluating your diabetes and changing its treatment is additional medical care, and your plan may apply a separate charge. Our team can help check the benefit and expected cost.
What if diabetes is only listed in the wellness history?
That alone does not establish a separate E/M. A copied condition list and medication reconciliation performed for the AWV are not an additional disease-management service.
CMS AWV guidance; 2026 National Correct Coding Initiative (NCCI) manual. NCCI edits specify code pairs and when a modifier may legitimately apply.
Finish an ordinary visit
- Identify the service and whether the patient is new or established under its rules.
- Choose MDM or qualifying time and identify the supporting facts.
- Keep separately reported work and its time distinct; check any needed modifier.
- Confirm that the note records the assessment, decisions, and follow-up. Route unresolved payer/edit questions to the coding team.
The sections below are references for services your practice offers. Open the relevant one when that work is part of the encounter.
Add-ons and special services
G2211: the ongoing care relationship
G2211 recognizes complexity associated with ongoing responsibility for the patient's care or a serious/complex condition. It accompanies an eligible E/M. It is not simply a bonus for any visit with a chronic diagnosis.
A medically necessary acute visit with a patient's usual primary care clinician can still occur within that ongoing relationship. A one-time urgent-care encounter without ongoing responsibility usually does not. A helpful sentence can clarify your role, but CMS does not require special wording.
Check both the base code and the relationship. Medicare permits G2211 with 99202–99205 or 99211–99215, and, beginning in 2026, eligible home/residence E/M codes. It cannot stand alone.
| Encounter | G2211 rule |
|---|---|
| Preventive service alone | No. A physical such as 99395, an AWV, or vaccine administration alone is not an eligible base E/M. |
| Routine postoperative care included in the global surgical payment | No separate G2211 for that bundled care. A postoperative reporting code such as 99024 is not an eligible base E/M. |
| One-time consultation or limited urgent-care encounter | No when there is no ongoing care responsibility. Consultation codes such as 99244 are also not eligible base codes. |
| Other service families | Do not attach G2211 to TCM (99495/99496), inpatient, emergency-department, or nursing-facility visit codes. |
| Procedure plus an office E/M with modifier 25 | Medicare generally denies G2211. A joint injection or skin procedure does not itself establish a preventive-service exception. |
The preventive-service exception: Medicare can pay G2211 with a qualifying problem E/M reported with modifier 25 when the same practitioner also provides an AWV, vaccine administration, or another eligible Part B preventive service that day. For example, G0439 + 99214-25 + G2211 may qualify when each service's requirements are met. An AWV alone does not. A routine physical such as 99395 does not itself establish this Medicare exception; check the commercial payer's policy for 99395 + 99214-25. Use CMS's eligible-service list rather than assuming every screening qualifies.
Recent surgery is not a blanket exclusion. Routine recovery care bundled into the surgeon's global payment cannot be turned into a separate E/M plus G2211. A separately payable PCP visit for diabetes or another medical condition may still qualify if the eligible E/M and ongoing-care requirements are met. Check who performed the surgery and whether postoperative care was transferred: not every service from another clinician is included in the surgeon's payment. Modifier 24 applies to an unrelated E/M by the same physician during the postoperative period when appropriate; it is not required merely because a patient recently had surgery.
CMS global surgery guide, including services outside the global payment and postoperative modifiers. G2211 still requires an independently eligible base E/M.
CMS G2211 FAQ; CMS preventive-services guidance.
ACP, tobacco counseling, cognitive assessment, and preventive assessments
| Service | Core rule | Document the actual work |
|---|---|---|
| Advance care planning (ACP) | 99497 at 16–45 minutes; add one 99498 at 46–75 minutes | Voluntary discussion, participants, preferences and decisions, and time. A completed legal form is not required. |
| Tobacco cessation counseling | 99406: more than 3 through 10 minutes. 99407: more than 10 minutes. | Use, counseling, readiness and plan, and exact counseling time. |
| Physical activity and nutrition assessment | G0136: revised 2026 description; 5–15 minutes, no more often than every six months | Indication, validated assessment tool, time, findings, and response. A generic social-needs screen is not the revised service. |
| Cognitive assessment and care plan | 99483: a comprehensive service with an independent historian and a written care plan | Cognition, function, safety, medications, behavioral and caregiver needs, care preferences, and the required plan. A brief memory screen alone is insufficient. |
For ACP furnished as an optional part of a qualifying AWV, modifier 33 identifies preventive treatment for cost-sharing purposes when requirements are met. Do not assume every ACP encounter is free to the patient. G0136 also has an AWV cost-sharing exception. Cognitive assessment cannot be stacked with office E/M or ACP on the same date; an AWV combination has its own requirements.
Service-specific sources: ACP, tobacco counseling, activity/nutrition assessment, and cognitive assessment.
See screening and counseling for depression, alcohol, and obesity services and the documentation that distinguishes them.
Screening and counseling
First identify the work: screening an asymptomatic patient, assessing a known condition, or providing a defined counseling service. Then check the payer's code, required time, frequency, and bundling rules. A questionnaire score or a diagnosis alone does not establish every service below.
| Service | Starting code | What the record should show |
|---|---|---|
| Standardized emotional or behavioral assessment | 96127, per instrument, when recognized | Instrument, score, interpretation, and response. Check whether the payer includes it in the preventive visit; it is not a generic time-based counseling code. |
| Medicare annual depression screening | G0444, 5–15 minutes | Screening performed, result, actual time, and follow-up. Requires a primary care setting with staff-assisted depression care supports; assessing symptomatic depression is a different service. |
| Medicare annual alcohol misuse screening | G0442, 5–15 minutes | Screening method, alcohol-use findings, result, time, and next step. |
| Medicare alcohol misuse counseling | G0443, 15-minute service | Qualifying positive screen, readiness, counseling, agreed goals, and actual time. Up to four covered sessions per year for eligible patients; this benefit is not treatment for alcohol dependence. |
| Medicare intensive behavioral therapy for obesity | G0447, 15-minute individual service | BMI of at least 30, eligible primary care practitioner/setting, counseling, behavioral goals, actual time, and follow-up. Visit-frequency and six-month response requirements apply. |
AAFP: standardized assessments and payer distinctions; 2026 CMS NCCI manual, Chapter XI for current screening descriptors and overlapping services; AAFP: Medicare screening and counseling opportunities; CMS: full service eligibility, timing, and frequency rules.
The same questionnaire can serve different purposes
A PHQ-9 administered as an eligible annual depression screen and a PHQ-9 used to follow an established depressive disorder may look identical. The purpose, assessment, and plan distinguish them. Do not report Medicare's preventive screening code for disease monitoring merely because the same form was used, or bill 96127 and G0444 for the same screening work.
Documentation outline: [Screening/monitoring] for [reason]. [Instrument] score [result], reviewed with patient. Interpretation and any indicated safety assessment: [findings]. Plan: [counseling, further evaluation, treatment/referral, and follow-up]. For a timed service: [actual qualifying minutes], excluding separately reported work.
Routine anticipatory guidance is part of the preventive physical. Separately reported counseling must meet its own requirements beyond included work. Likewise, review AWV/IPPE bundling before adding a screening code: Medicare includes depression-risk review in the IPPE and initial AWV. The existence of a separate code does not override an applicable edit. Document actual minutes and apply that service's time rule; do not assume every timed code follows ACP's midpoint rule.
AAFP: screening, monitoring, and bundled services. Tobacco counseling is in special services; vaccine product and administration billing is in Office Procedures. Reviewed September 17, 2026.
Document advance care planning
Advance care planning (ACP) gives a patient, family member, or surrogate time to discuss future medical decisions and advance directives with a physician or other qualified health care professional. “Advance directive discussed” alone does not show a separately billable service. Record the conversation and the time actually devoted to it.
What belongs in the note
- Voluntary participation: document that the patient or appropriate representative agreed to the discussion. Explain any expected cost sharing.
- Participants: identify those present and their roles. If a surrogate participates for the patient, explain the circumstances and the patient's ability to participate.
- Advance-directive counseling: describe what you explained or reviewed, such as choosing a health care agent or recording treatment wishes if the patient cannot decide.
- Preferences and next steps: record the patient's priorities, decisions made or deferred, forms reviewed or completed, and follow-up. Distinguish a person the patient hopes to appoint from an already documented health care agent.
- Time: state the actual qualifying face-to-face ACP minutes. Start and stop times can make the record clearer; CMS's national guidance requires the time spent, not a particular sentence or template.
CMS specifically calls for voluntariness, advance-directive explanation, participants, and face-to-face time. The additional clinical details make the discussion useful to the next clinician. A patient may defer a decision or leave without a signed directive and still receive a qualifying ACP service.
AAFP: ACP documentation and billing; CMS ACP fact sheet, March 2026.
A documented 20-minute conversation
Fictional documentation example; use only findings and time that reflect the encounter.
Patient agreed to voluntary advance care planning after we discussed its purpose and potential cost sharing. Patient and daughter Maya participated in person; the patient was able to understand the options and express preferences. We reviewed how a health care agent would make decisions if the patient could not, and how an advance directive records treatment wishes. The patient would like Maya to serve as agent but has not completed an appointment document. Remaining able to recognize and interact with family is a priority. The patient wants more time to consider preferences about prolonged life support. We reviewed the directive form; no form was signed and no resuscitation order was changed today. Patient plans to discuss preferences with Maya and bring the document to follow-up next month. I personally spent 20 minutes face-to-face on ACP, 10:05–10:25, separate from the other services provided today.
The documented discussion and time can support 99497, subject to the applicable payer rules. Signing a form, choosing a DNR order, or making a final decision is not a prerequisite. Do not copy the sample's time or preferences into another patient's record.
Count ACP time separately
| Qualifying ACP time | Codes and units |
|---|---|
| 15 minutes or less | No separate 99497 or 99498 |
| 16–45 minutes | 99497, one unit |
| 46–75 minutes | 99497, one unit, plus 99498, one unit |
| 76–105 minutes | 99497, one unit, plus 99498, two units |
For an in-person encounter, count qualifying face-to-face ACP time; do not add later charting to reach 16 minutes. Exclude separately reported ACP work, including its documentation, from time used to select an office E/M. For example, 20 minutes of ACP plus 25 qualifying office E/M minutes does not create a 45-minute office E/M. The separate established-patient E/M would support 99213 by time, or another level if its own MDM supports it. Apply modifier 25 to a significant, separately identifiable office E/M when required by the payer.
AAFP: ACP time thresholds; AAFP: separating ACP and office E/M time.
Wellness visits and repeat discussions
For traditional Medicare to waive ACP deductible and coinsurance, provide ACP with a covered G0438 or G0439 AWV on the same day, by the same provider, on the same claim, with modifier 33 on the ACP code(s). Otherwise, usual Part B cost sharing applies. An AWV denied for exceeding its frequency limit also loses this ACP cost-sharing waiver.
Medicare does not impose a fixed ACP frequency limit. When billing it again, document the change in health status, end-of-life wishes, or both that prompted the new discussion. A copied prior note does not describe today's work. No single diagnosis code is mandatory; report a diagnosis appropriate to the encounter.
CMS: AWV cost sharing, repeat ACP, and diagnosis reporting. Reviewed September 17, 2026.
Care across days and months
These services pay for defined care-management work beyond an ordinary visit. Choose the program that fits the patient's needs and your team's capabilities. The references below cover CCM, behavioral health integration, and remote monitoring, alongside TCM and APCM.
Transitional care management: the discharge is the starting point
TCM covers a 30-day transition after a qualifying facility discharge to a community setting. It includes work outside the visit. Contact the patient or caregiver within two business days to assess needs, not merely schedule. Complete medication reconciliation by the face-to-face visit.
99495 requires at least moderate MDM and a face-to-face visit within 14 calendar days. 99496 requires high MDM and a visit within seven. If contact fails, at least two separate timely attempts must be documented, attempts must continue, and the remaining requirements must be met. Do not separately bill the included face-to-face E/M.
The early visit does not determine the TCM level
A patient is seen five days after discharge. Contact, medication reconciliation, and other TCM requirements are met, but MDM is moderate.
Consider 99495, not 99496. Meeting the tighter visit deadline does not create high MDM. If the TCM requirements fail, assess the office service actually performed rather than forcing a TCM code.
Advanced primary care management: a practice capability
APCM is a monthly primary care service, not a per-message charge. G0556 is the base level; G0557 requires at least two qualifying chronic conditions; G0558 also requires Qualified Medicare Beneficiary (QMB) status. The chronic conditions must meet the duration and significant-risk criteria.
The practice must meet the service requirements: consent, an initiating visit when required, access and continuity, care planning, transition coordination, population management, and applicable performance measurement. Only one provider bills APCM for the patient-month. Provide the relevant elements as needed; it is not necessary to perform every element every month.
Before enrollment, verify how your team meets the full requirements and what other services the bundle includes. Online digital E/M and several other communication/care-management services overlap with APCM and cannot simply be added again.
CMS APCM requirements; AAFP APCM billing and included services.
Chronic care management: document the month, not just the diagnoses
CCM requires at least two chronic conditions expected to last 12 months or until death, with significant risk of death, exacerbation/decompensation, or functional decline. Medicare requires documented consent covering possible cost sharing, one billing practitioner per month, and the right to stop. An initiating visit is required for new patients or those not seen within the previous year.
The practice must provide the care plan, continuity, access, and coordination required by the service. A list of chronic diagnoses and an automated monthly charge do not demonstrate CCM.
CMS: CCM eligibility, consent, and practice requirements.
| Pathway | Base service per calendar month | Additional time |
|---|---|---|
| Noncomplex CCM, clinical staff under clinician direction | 99490: at least 20 minutes | 99439: each additional 20 minutes |
| CCM personally provided by physician/QHP | 99491: at least 30 minutes | 99437: each additional 30 minutes |
| Complex CCM | 99487: at least 60 minutes of clinical staff time, moderate/high MDM, and establishment or substantial revision of the care plan | 99489: each additional 30 minutes |
Meet the full time threshold; do not round 18 minutes up to 20. Check add-on unit limits and choose the appropriate pathway rather than combining these mutually exclusive CCM pathways in one month.
Twenty-four documented minutes
Fictional example. An eligible, consented patient has a current comprehensive care plan. Under the billing clinician's direction, an RN spends 12 minutes resolving a diabetes medication-access problem and 12 minutes coordinating the heart-failure monitoring plan. The record identifies dates, staff member, actions, outcomes, and 24 unduplicated qualifying minutes.
If the remaining CCM requirements are met, this supports 99490. Eighteen minutes would not. Time already reported for a separate visit or another management service cannot be counted again.
CCM and APCM are alternative billing pathways for overlapping work. Do not add CCM to APCM for the same patient-month. APCM is not selected by a monthly minute threshold. Verify other concurrent-service rules before submitting claims.
AAFP: CCM code families and documentation; CMS: APCM bundled services.
Behavioral health integration and psychiatric collaborative care
General BHI supports organized behavioral-health care management: assessment with appropriate rating scales, an evolving care plan, treatment coordination, and continuity. 99484 requires at least 20 minutes of qualifying clinical staff time per calendar month under the treating clinician's direction. A psychiatric consultant is optional for general BHI.
Psychiatric collaborative care (CoCM) adds a behavioral health care manager, psychiatric consultant, systematic registry tracking, and regular case review with treatment recommendations. Its main codes are 99492 for the initial month, 99493 for subsequent months, and 99494 for additional time. Use the full CoCM time rules; a routine medication visit or screening score alone does not establish this service.
Document consent, an initiating visit when required, the condition and goals, rating-scale trends, team contacts, care-plan changes, and qualifying time by person and activity. Include psychiatric case-review recommendations for CoCM. General BHI and CoCM are not both billed for the same patient-month. When another care-management service is allowed concurrently, its work and time must remain distinct.
AAFP: BHI and CoCM roles, consent, and concurrent billing.
2026 APCM option: Medicare offers non-time-based add-ons G0568 and G0569 for psychiatric CoCM, and G0570 for general BHI, when an APCM base code is billed for the same month and all service requirements are met. These are not automatic additions for a depression diagnosis. Select the applicable pathway and check overlapping-code exclusions.
Remote patient monitoring: distinguish the device from the management
Remote physiologic monitoring (RPM) can support care for an acute or chronic condition using a qualifying medical device that automatically transmits measurements, such as blood pressure. Medicare requires medical necessity, an established patient relationship, and consent. A patient sending a photograph of a handwritten BP log does not establish the RPM device service.
| Component | Codes to check | Record |
|---|---|---|
| Setup and education | 99453 | Device setup and patient instruction; not a recurring monthly setup charge. |
| Device supply and transmission | 99445: 2–15 data days; 99454: 16 or more, in a 30-day period | Device, monitoring period, and qualifying transmission days. Select the applicable tier, not both for the same period. |
| Treatment management | 99470: first 10 minutes; 99457: first 20 minutes; 99458: additional 20-minute units with 99457 | Qualifying calendar-month time, findings, management decisions, and required real-time interaction with the patient/caregiver. Verify the applicable thresholds and combination rules. |
The lower-duration codes 99445 and 99470 are new for 2026. Device-supply days and treatment-management minutes measure different work. Do not infer that a device transmission automatically supports a management charge.
CMS: RPM eligibility and service components; CY 2026 Physician Fee Schedule final rule: remote monitoring code changes.
Keep the indication, consent, device information, transmission dates, review findings, patient communication, and resulting plan together. For example, 12 qualifying transmission days may support the shorter device tier when the remaining requirements are met; a separate record must support any treatment-management code. A BP trend copied into a monthly note does not demonstrate that management occurred.
Only one practitioner may bill remote monitoring for a patient in a 30-day period. Medicare does not allow RPM and remote therapeutic monitoring together. Permitted combinations with other care-management services still cannot reuse the same work or minutes.
CMS: remote monitoring requirements and concurrent services. Monthly-service references reviewed September 17, 2026.
Cases to work through
For each case, identify the service, the supporting facts, and the missing fact that could change your answer.
1. “HTN, diabetes. Medications reviewed. Follow up.” Can you assign moderate MDM from this note?
There is insufficient information. The condition list does not tell you whether both illnesses were assessed, their status, or what management decisions were made. Review the actual encounter for supporting work; clarify omissions accurately without inventing findings. If adequate documentation shows two stable illnesses addressed and prescription management, those elements can support moderate MDM. The short note alone does not establish that.
2. You interpret an ECG and separately report that interpretation, order one lab, and manage one stable illness. Does “lots of data” establish 99214?
No. Do not count your separately reported ECG interpretation toward this E/M’s data element. A lab order alone does not establish moderate data. Look for a second moderate MDM element or qualifying time before selecting 99214.
3. A patient comes only for an injection. You confirm the indication and obtain consent. Add an office visit?
Not for that routine procedure work alone. Start with the procedure. A separately reportable E/M requires additional significant, identifiable assessment and management. Neither the appointment length nor the fact that you spoke with the patient proves it.
4. ACP lasts 35 minutes; tobacco counseling lasts exactly 3 minutes. Which separate timed codes qualify?
For otherwise qualifying ACP, 99497 alone. The first 99498 starts at 46 minutes. Three minutes of tobacco counseling does not qualify for 99406. Do not borrow time from another service to reach a threshold.
5. You arrange hospitalization for a serious acute illness. What makes the MDM high?
The documented illness threatens life or bodily function, meeting the high problem element, and the hospitalization decision meets high management risk. Explain the assessment and disposition. An ED referral by itself, without a second high element, is not a complete high-MDM argument.
Reference and sources
2026 office and selected service RVUs
National non-facility values from CMS RVU26B, updated May 1, 2026. Work / total are different measures. Geography, conversion factor, payer contract, and other adjustments affect payment; employment agreements determine compensation credit.
| Code | Work | Total |
|---|---|---|
99202 / 99203 / 99204 / 99205 | 0.93 / 1.60 / 2.60 / 3.50 | 2.25 / 3.52 / 5.31 / 7.09 |
99212 / 99213 / 99214 / 99215 | 0.70 / 1.30 / 1.92 / 2.80 | 1.78 / 2.85 / 4.06 / 5.76 |
G2211 / G2212 | 0.33 / 0.61 | 0.52 / 1.02 |
G0402 / G0438 / G0439 | 2.60 / 2.60 / 1.92 | 5.23 / 5.22 / 4.12 |
99483 | 3.84 | 8.77 |
99495 / 99496 | 2.78 / 3.79 | 6.59 / 8.94 |
G0556 / G0557 / G0558 | 0.25 / 0.77 / 1.67 | 0.49 / 1.61 / 3.51 |
Before billing, verify the payer policy, applicable NCCI edits, frequency limits, and full code requirements.