Glossary · Coding

Evaluation and management (E/M)

Evaluation and management (E/M) codes are CPT codes that describe cognitive clinical services—history-taking, examination, and medical decision-making—as opposed to procedural or surgical work. In orthopedics, they are used to bill office visits, consultations, and hospital encounters that are not bundled into a surgical global period.

Verified May 8, 2026 · 6 sources ↓

Drawn from CMSAoassnAAPCAdscOutsourcestrategies

Definition

Source · Editorial summary grounded in 6 cited references ↓

E/M codes occupy the 99202–99499 range of the CPT code set and represent the physician's intellectual work during a patient encounter: assessing a problem, weighing diagnostic options, and formulating a treatment plan. Each code level corresponds to increasing complexity of medical decision-making (MDM) or increasing total time spent on that calendar date. Since 2021, CMS eliminated history and physical exam as determinants of E/M level for office visits; MDM and time are now the only two pathways for selecting the correct code. This change benefited orthopedic surgeons, whose cognitive work is concentrated in decision-making rather than multi-system examinations.

For orthopedic practices, E/M codes most commonly appear in two contexts. First, as standalone visit codes for new or established patients who are not in a surgical global period (e.g., 99203–99205 for new patients, 99213–99215 for established patients). Second, as separately reportable services during a global period when the encounter addresses a problem unrelated to the original surgery—requiring modifier 24 to bypass the global package edit.

Level selection must be defensible in the medical record. MDM is assessed across three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications or morbidity associated with management options. Billing a higher-complexity level (e.g., 99215) without documented high-complexity MDM is one of the most audited patterns in orthopedic office billing.

Why it matters

Mis-leveled E/M codes expose orthopedic practices to two distinct financial risks simultaneously. Upcoding—billing a 99215 when MDM supports only a 99213—triggers post-payment audits and recovery demands from Medicare and commercial payers. Downcoding—reflexively billing 99213 for every established patient out of caution—leaves real reimbursement on the table on every encounter. CMS publishes E/M utilization data by specialty, and outlier patterns at either end of the spectrum attract scrutiny. Additionally, billing any E/M during a global period without the correct modifier causes automatic denial, because the payer's edit system treats routine follow-up as bundled into the surgical payment already made.

Common mistakes

Where people most often go wrong with this concept.

Source · Editorial brief grounded in cited references ↓

Selecting E/M level based on the length or detail of the physical exam rather than the MDM or total time—a pre-2021 habit that no longer governs code selection.
Billing a separate E/M on the same day as a minor procedure without appending modifier 25 to establish that a separately identifiable service was performed.
Billing an E/M visit during the surgical global period without modifier 24, causing the claim to be denied as bundled follow-up care.
Using time as the basis for E/M level without documenting the start and stop time—or total time—in the medical record on that date of service.
Defaulting to a low-level established-patient code (99213) for all fracture or post-op follow-ups when the documented MDM supports a higher level, resulting in systematic undercoding.
Applying the wrong E/M category entirely—for example, billing an office visit code for a service that should be billed as a hospital observation or inpatient code, which carry different documentation requirements and reimbursement rates.

Related codes

Codes commonly involved when this concept appears in practice.

CPT

ICD-10

M17.11 M17.12 M75.41 M51.26

Modifiers

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01What changed about E/M coding in 2021 that affects orthopedic practices?

CMS eliminated history and physical exam as factors in determining office visit E/M level. Since 2021, the code level is determined solely by medical decision-making complexity or total time spent on the date of service. For orthopedic surgeons, this is generally favorable because the cognitive weight of an orthopedic encounter sits in MDM—problem assessment, imaging interpretation, and treatment planning—rather than in a lengthy multi-system physical exam.

02Can an orthopedic surgeon bill an E/M visit during the post-operative global period?

Yes, but only with the correct modifier. If the E/M visit addresses a problem that is unrelated to the original surgery, modifier 24 must be appended to signal to the payer that the service falls outside the global package. Without modifier 24, the claim will be denied automatically as bundled follow-up care, even if the clinical reason is entirely separate.

03What is the difference between modifier 24 and modifier 25 in the E/M context?

Modifier 24 is used when a separate E/M is billed during a post-operative global period for an unrelated problem. Modifier 25 is used on the same day as a minor procedure to indicate that a separately identifiable E/M service—beyond the typical pre-procedure assessment—was performed. Using the wrong modifier, or omitting it, results in either a denial or a compliance risk if the modifier is applied without supporting documentation.

04How does time-based E/M billing work, and what must be documented?

When using total time as the basis for E/M level selection, the provider must document the total time spent on the patient's care on that calendar date, including face-to-face and non-face-to-face work such as reviewing records and coordinating care. The documented time must meet or exceed the published threshold for the selected code. Documenting only 'spent 30 minutes with patient' without specifying it is total time for that date does not adequately support time-based billing.

05Are workers' compensation E/M visits coded differently in orthopedics?

The same CPT E/M codes apply, but ICD-10 coding requirements differ. Workers' compensation payers typically require external cause codes that document the mechanism and circumstances of the injury alongside the primary diagnosis code. Missing these codes can result in denials or delays specific to workers' comp claims, even when the E/M level itself is correctly selected.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira reviews each completed orthopedic encounter note and maps the documented clinical elements to the correct E/M level before the claim is generated. For the MDM pathway, Mira evaluates three axes in the note: the number and acuity of problems addressed, the complexity of data reviewed (labs, imaging, external records, independent interpretation), and the risk tier of the management plan. If the note supports high-complexity MDM—for example, an undiagnosed new problem with workup ordered plus a prescription drug management decision—Mira flags 99215 as the appropriate code and surfaces the supporting documentation passages so the coder can confirm before submission. For time-based billing, Mira identifies when a provider has documented total time on the date of service and cross-checks whether that time threshold meets or exceeds the minimum for the selected code level. If the documented time falls in a different code's range than what was pre-selected, Mira generates an alert. When an E/M is generated during an active surgical global period, Mira automatically evaluates whether the encounter reason is related or unrelated to the original procedure. If unrelated, it appends modifier 24 to the E/M code. If same-day minor procedure and E/M are both present, Mira checks whether a separately identifiable service is documented and, if so, appends modifier 25. These checks run prior to claim submission and are logged in the audit trail for compliance review.

See Mira's approach

Related terms

Global period Coding

The global period is the defined window of time—0, 10, or 90 days—during which Medicare and most payers consider routine pre- and post-operative care to be bundled into the payment for the surgical procedure itself. For major orthopedic surgery, that window is 90 days.

CPT code Coding

A CPT code is a standardized five-digit numeric code, maintained by the AMA, that identifies a specific medical or surgical service for billing and reimbursement purposes. In orthopedics, CPT codes cover everything from office visits and joint injections to complex spinal fusions and total joint replacements.

Relative Value Unit (RVU) Reimbursement

A Relative Value Unit (RVU) is a numeric weight assigned to each CPT code that quantifies the resources required to perform a medical service; when multiplied by a conversion factor and geographic adjustments, it determines Medicare and commercial payer reimbursement.

Bundling Coding

Bundling is the payer rule that treats two or more CPT codes as a single reimbursable unit, paying only the primary code when the secondary procedure is considered an inherent or integral part of it. Billing the bundled codes separately without proper justification constitutes unbundling, a compliance violation.