January 11, 2021
Fact Sheet - Physician Fee Schedule (PFS) Payment for Office/Outpatient Evaluation and
Management (E/M) Visits
Effective January 1, 2021, for PFS payment of office/outpatient E/M visits (CPT codes 99201
through 99215), Medicare generally adopts the new coding, prefatory language, and interpretive
guidance framework that has been issued by the AMA's CPT Editorial Panel (available at the
following website: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-
management).
Practitioners will no longer use history and exam to select the office/outpatient E/M visit level.
Instead, an office/outpatient E/M visit includes a medically appropriate history and exam, when
performed. Practitioners should perform history and exam to the extent clinically appropriate,
and reasonable and necessary.
patient). For levels 2 through 5 office/outpatient E/M visits, practitioners report visit level based
upon either the level of medical decision-making as revised in the AMA/CPT guidance, or the
total time personally spent by the reporting practitioner on the day of the visit (including face-to-
face and non-face-to-face time).
ADD-ON CODE FOR PROLONGED VISITS
When the practitioner selects a visit level using time, the practitioner may report prolonged
office/outpatient E/M visit time using HCPCS add-on code G2212 (Prolonged office/outpatient
E/M services). Practitioners should not report prolonged office/outpatient E/M visit time using
CPT codes 99354 and 99355 (Prolonged service with direct patient contact), 99358 and 99359
(Prolonged service without direct patient contact), 99415 and 99416 (Prolonged clinical staff
services), or 99417 (Prolonged office/outpatient E/M services with or without direct patient
contact). The following table provides reporting examples.
HCPCS Code(s) Total Time Required for Reporting*
99215 x 1 and G2212 x 3 or more for each additional 15 minutes.
*Total time is the sum of all time, including prolonged time, spent by the reporting practitioner on the date of
service of the visit.
HCPCS code G2212 (Prolonged office or other outpatient evaluation and management
service(s)
beyond the maximum required time of the primary procedure which has been selected
using total time on the date of the primary service; each additional 15 minutes by the physician
or qualified healthcare professional, with or without direct patient contact (List separately in
addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management
services). (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359,
99415, 99416). (Do not report G2212 for any time unit less than 15 minutes)).