Department of Neurology







Knowledge of E/M coding and documentation is essential in order to 1) correctly bill and obtain reimbursement for the work you do; and 2) avoid legal ramifications of audits for improperly documented medical records. The most recent E/M coding and documentation rules are found in the 1997 Documentation Guidelines for Evaluation and Management Services, from the Center for Medicare & Medicaid Services (CMS). A simplified approach, tailored for neurology follows below, based first on determining the level of Medical Decision Making.

The documentation of all E/M codes involves (3) components:

•  History

•  Physical Examination

•  Medical Decision Making

Among these three components, it is the Medical Decision Making (MDM) that is most patient specific. The MDM in essence drives which E/M code to use. Among other factors, it incorporates the severity of the illness, the complexity of the case, review of outside records, and undertaking diagnostic testing and treatment. Thus, one of the best approaches to E/M coding is to first determine the level of MDM (click here to learn how to determine the level of MDM). Once that is determined, the proper E/M code is determined. Then it is straightforward of to determine how much and what detail of History and Physical Examination must be documented.

Selection of the Proper E/M Code and Documentation of the Required History and Examination

Once the level of MDM is determined, the correct E/M code is selected depending on whether the visit is a consult, new or established patient visit.

New vs Established

A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. Please note that the three-year rule does not apply to consultations. Also, CMS considers Vascular Neurology, Neuromuscular Medicine and Clinical Neurophysiology as separate and distinct specialties.

Consultation vs a New Referral

What is the difference between a Consultation and a New Patient. For a consultation, remember the 3 R's:

There must be a Requesting physician who wants you to Render an opinion and then send a Report. You can have repeat consultations for the same or different problem. Consultations do not involve active management of patient problems although the consultant may initiate diagnostic and/or the therapeutic services. If responsibility for ongoing care is assumed, subsequent services are no longer consultations, but established visits.

A new patient referral, on the other hand, occurs when there is the intent of the referring physician to transfer the total or specific care of a patient to you. In the case of a new referral, no written letter or report is required.

Once the code is selected, then there is specific history and exam documentation required for that code (click on each code below to review the specific documentation requirements). To see an overview of all the history and exam documentation requirements, click here.

Outpatient E/M Codes for Neurology

Levels 3, 4 and 5

Level of MDM Consultation New Patient Established Patient

Low Complexity
99243 99203 99213

Moderate Complexity
99244 99204 99214

High Complexity
99245 99205 99215

The above lists the most commonly used E/M codes in outpatient neurology: levels 3, 4 and 5 (low, moderate and high complexity, respectively). For levels 1 and 2, click here.

Alternative E/M Coding: Using Time

If you document the total time and note that counseling and coordinating care required more than 50% of the encounter, then time may be used to determine the level of service. Documentation may refer to:

•  diagnostic results, impressions and plans for other studies

•  prognosis

•  differential diagnosis

•  risks, benefits of treatment

•  instructions

•  compliance

•  risk reduction

•  patient and family education

The average total times (face-to-face with the patient and/or family) for the common E/M outpatient codes are listed below. For inpatient admissions and subsequent daily care, face to face time with the patient and family are counted, as well as any time spent on the floor / unit in the care of the patient (e.g., reviewing films, writing notes, etc.).

Consultations New Patients Established Patients
Level 3 - 99243 40 minutes Level 3 - 99203 30 minutes Level 3 - 99213 15 minutes
Level 4 - 99244 60 minutes Level 4 - 99204 45 minutes Level 4 - 99214 25 minutes
Level 5 - 99245 80 minutes Level 5 - 99205 60 minutes Level 5 - 99215 40 minutes

Condensed E/M Coding for Outpatient Neurology Sheet (pdf): 

Two page file that can be printed for quick reference in the office setting (Download here)

Legal disclaimer: the above information regarding outpatient E/M codes is deemed reliable. However, physicians should always confirm the information in the 1997 CMS guidelines.