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Coding and payment

Understanding evaluation and management services in ID care

Evaluation and management services are cognitive (as opposed to procedural) services in which a physician or other qualified health care professional diagnoses and treats illness or injury. Nearly all physicians provide E/M services. However, most services that infectious diseases physicians provide are of the E/M type.

Appropriate documentation and coding of E/M services are vital to capturing the medical services provided to infectious diseases patients and, therefore, are also vital for appropriate reimbursement and compensation. IDSA has curated resources for ID physicians and their staff to better understand E/M coding.

 

 

In the Know

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FAQs

Billing and coding FAQs

IDSA’s Coding and Payment Subcommittee has developed FAQs about billing and coding to help ID physicians and their staff.

Accurate coding and billing can result in more appropriate and timely reimbursement, while also protecting against claims denials and audits. Understanding coding and billing is an essential component of advancing ID physician compensation.  

“QHCP” is a qualified health care professional, defined by the American Medical Association as “an individual who is qualified by education, training, licensure/ regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service.” 

“NPP” is used by Medicare and other payers to describe a non-physician practitioner, such as a physician assistant and nurse practitioner. 

No. Split or shared visits are visits in the outpatient setting that are shared between a physician and NPP within the same group practice. This means that both a physician and an NPP have face-to-face contact with the patient during the same visit. “Incident to” services are those that are furnished as an integral, although incidental, part of a physician’s professional service in the course of diagnosis or treatment of an injury or illness. These services must be performed in a non-hospital setting and under the direct supervision of a physician. The services are typically performed by NPPs. Please see Split or Shared Visits (insert hyperlink) and “Incident To” (insert hyperlink) for specific information regarding these types of visits. 

Level of service selection is based on medical decision making or time, but it is important to document an appropriate history and physical examination, when performed, as this documentation can also support the level of service selected. It is also important to appropriately document the patient encounter, including history and physical examination, when performed, to convey information and plan of care in the medical record to other clinicians. 

 

A patient is considered “new” to the provider if that patient has not received any professional service from that provider or any other provider in the same group within the previous three years. 

When a physician or QHCP is covering for another physician/ QHCP, then the encounter would be billed as if the unavailable provider is doing the encounter (i.e., it would not count as a new patient or visit).

Ask the Coder

Webinar resources

  • Add-On Code (G0545) link

    The new ID add-on code, G0545, went into effect on Jan. 1, 2025. This code is available for infectious diseases specialists to report additional complexities in hospital evaluation and management services. In this webinar, Drs. Amy Kressel and Asher Schranz discuss the G0545 code and how to use it.

  • New Webinar: CPT Code G2211 for ID Physicians link

    Dr. Timothy Sullivan, vice chair of IDSA’s Coding & Payment Subcommittee, and Dr. John Fangman, member of both HIVMA's and IDSA’s Coding & Payment Subcommittee, discuss the new G2211 code introduced in the 2024 evaluation and management services revisions by the Centers for Medicare & Medicaid Services. In this 10-minute informational video, they discuss how this code can be used by ID clinicians with real-world examples.

  • Learn from the ID Experts: Navigating the Revised CPT® Codes for Office and Outpatient E/M Services link

    Revised CPT codes and associated documentation for office/outpatient evaluation and management services are now in effect. Dr. Ronald Devine and Dr. Prashant Malhotra, IDSA members and CPT code experts, explain the revisions and how to navigate the changes. This webinar was created specifically for ID physicians.

Resources

  • CMS E/M Guide pdf

    MLN006764 September 2024 Fee schedules, relative value units, conversion factors and/or related components are not assigned by AMA, are not part of CPT, and AMA is not recommending their use. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein.

  • CPT® Evaluation and Management link

    On Nov. 1, 2019, the Centers for Medicare and Medicaid Services finalized a historic provision in the 2020 Medicare Physician Fee Schedule Final Rule. This provision includes revisions to the evaluation and management office visit CPT codes (99201-99215) code descriptors and documentation standards that directly address the continuing problem of administrative burden for physicians in nearly every specialty, from across the country.

  • Revisions to the CPT E/M Office Visits: New Ways to Report Using Time link

    Substantive revisions have been made to the CPT codes related to office and other outpatient services, collectively known as the evaluation and management codes. This second module, in a series of three, will provide detailed information on how the revisions to the CPT E/M office visits will affect time.

  • Code G2211 Fact Sheet pdf

    All medical professionals who can bill office and outpatient evaluation and management visits (CPT codes 99202-99205, 99211-99215), regardless of specialty, may use the code with O/O E/M visits of any level. We don’t restrict G2211 to medical professionals based on specialties.

  • Split/Shared Resources pdf

    Infographic: Physician and Physician Assistant or Nurse Practitioner Work Together to Perform the Evaluation and Management Service

  • G0545 Q&A Resource pdf

    To further support ID specialists, we have compiled a Q&A resource addressing questions asked during the G0545 webinar. Whether you attended the webinar or are looking for additional guidance, this Q&A is a helpful reference for effectively navigating the new add-on code G0545.

  • ID Add-On Code G0545 pdf

    To help ID specialists navigate the proper use of add-on code G0545, IDSA has created an infographic checklist outlining the key criteria that must be met (one from each section MUST be met). This visual guide serves as a quick reference to ensure proper usage. Use this checklist to verify that all necessary requirements are met before applying the code. IDSA will continue to update the resources on this page for code G0545 as CMS provides further clarification.

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