E&M CPT codes

New patient office or outpatient visit requiring high-complexity medical decision making, or 60–74 minutes of total time on the date of encounter.

Highest-level office or outpatient E/M visit for an established patient, qualifying via high-complexity medical decision making or 40–54 minutes of total provider time on the date of service.

New patient office or outpatient visit requiring moderate medical decision making, or 45–59 minutes of total provider time on the date of the encounter.

Office visit for an established patient requiring moderate-complexity medical decision making (MDM), or 30–39 minutes of total provider time on the date of service.

New patient office or outpatient visit requiring a medically appropriate history and/or examination with low-complexity medical decision-making, or 30–44 minutes of total provider time on the date of the encounter.

High-complexity physical therapy evaluation requiring documentation of three or more personal factors or comorbidities affecting the plan of care, examination of four or more body system elements using standardized tests and measures, and an unstable or unpredictable clinical presentation — typically 45 minutes face-to-face.

Moderate-complexity physical therapy evaluation requiring documented history with one to two comorbidities or personal factors, examination of three or more body system elements with measurable findings, and moderate clinical decision-making for an evolving presentation — typically 30 minutes face-to-face.

Low-complexity occupational therapy evaluation, typically 30 minutes face-to-face, for patients with no comorbidities affecting occupational performance and a limited set of treatment options.

Occupational therapy initial evaluation at high complexity, involving extensive history review, assessment of five or more performance deficits, and high-analytic-complexity clinical decision-making — typically 60 minutes face-to-face.

Low-complexity physical therapy evaluation covering a history with no or minimal comorbidities affecting the plan of care, examination of 1–2 elements (body structures/functions, activity limitations, and/or participation restrictions), a stable and uncomplicated clinical presentation, and low-complexity clinical decision-making. Typically 20 minutes face-to-face.

Established patient office or outpatient visit requiring 20–29 minutes of total time or low-complexity medical decision-making.

Remote evaluation and management visit for an established patient, lasting approximately 15 minutes, conducted in real time via interactive audio and video technology — restricted to use within a CMS Innovation Center demonstration project.

Re-evaluation of an occupational therapy established plan of care when a documented change in functional or medical status requires a revised care plan and updated occupational profile.

Physical therapy re-evaluation of an established plan of care, including interval history review, standardized tests and measures, and a revised plan of care using measurable functional outcome tools — typically 20 minutes face-to-face.

Initial physician or allowed practitioner certification for Medicare-covered home health services, performed without the patient present, including HHA contact and plan-of-care review.

Physical performance test or measurement, reported in 15-minute units, requiring a written report of results.

Range of motion measurements and report for the hand, with or without comparison to the uninvolved side.