Compliance with the latest E/M coding updates is critical for internists managing chronic and complex conditions.
Over the past few years, the AMA and CMS have rolled out significant changes, including revised documentation rules, adjusted time thresholds, and refined MDM scoring.
With further adjustments possible in 2025, internal medicine practices must stay informed to ensure accurate coding and billing.
Comprehensive internal medicine billing services can support proper E/M coding under the new rules for internists looking to streamline reimbursement and minimize compliance risks.
This guide breaks down what’s changed, what it means for your practice, and how to adapt effectively. Keep reading for a detailed look at the updates and actionable tips.
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Table of Contents
What Are the 2025 E/M Coding Changes for Internists?
In 2025, the new E/M coding standards prioritize Medical Decision-Making (MDM) over history and exam, streamline time-based thresholds, and clarify the rules for split/shared visits, prolonged services, and telehealth billing.
These updates are based on the AMA CPT code set and CMS guidelines. Pair these updates with a compliant RCM workflow. Our Internal Medicine Revenue Cycle Guide covers denial prevention and documentation best practices.
| Change Area | 2025 Update | Affects Internists By |
|---|---|---|
| MDM-Based Coding | The MDM is the primary driver of the E/M code, with levels of MDM (straightforward, low, moderate, high) determining the code based on the complexity of the problem, the amount of data reviewed, and the risk involved. | It is important for internists to understand MDM levels in order to select the appropriate codes based on the complexity of the problem and the data. |
| Time Thresholds Updated | There is now a minimum time requirement for time ranges. | During time-based coding, the total time spent must be documented. |
| Prolonged Services | CPT 99417 applies only to 99205/99215 outpatient visits; CPT 99418 applies to inpatient/observation. Prolonged services can be reported when the total time exceeds the highest-level base code by 15 minutes (e.g., 55+ minutes for 99215 [40+15], 75+ minutes for 99205 [60+15]). | Visits that exceed time thresholds qualify for prolonged service coding, regardless of complexity. |
| Split/Shared Visits | Billing determined by who performs >50% of the total time (Medicare) or MDM (private payers, if allowed). | Internist must document their role (time spent or MDM contributions). |
| Telehealth | CMS permits audio-only visits for select services; however, CMS may require the availability of audiovisual capability, even if the patient does not utilize it. | Remote services provide increased flexibility in coding for chronic care management; however, internists must verify payer-specific telehealth rules to ensure compliance. |
| Hospital/Subsequent Care | The time thresholds have been removed, and only MDM is used. | It emphasizes the risk and complexity of the exam over its length. |
How Do Internists Use MDM to Determine E/M Levels?
MDM determines E/M visit levels based on three key factors:
- Problem complexity
- Data reviewed
- Patient risk
Leveraging billing software optimized for internal medicine can reduce documentation gaps and automate MDM tracking under 2025 rules.
Key Reminder: Always verify with current CPT guidelines and payer-specific policies. For specialty-specific denial prevention strategies tailored to MDM-based coding, see our internal medicine AR optimization guide.
The Four Levels of MDM:
1. Straightforward MDM
Problem:
1 self-limited/minor issue (e.g., viral URI, uncomplicated rash).
Data Reviewed:
No tests or external records.
Risk:
Minimal (OTC meds, observation).
CPT Note: “Self-limited” requires documentation of expected resolution without treatment.
2. Low MDM
Problem:
- 2+ self-limited issues OR
- 1 well-documented stable chronic condition (e.g., “HTN controlled on amlodipine, BP 122/78 at last 3 visits”).
Data Reviewed:
- 1-2 labs/tests without independent interpretation OR
- Review of 1 external record (e.g., PCP note).
Risk:
- Low (e.g., topical steroids, 7-day antibiotics).
Payer Alert: Some insurers require chronic conditions to have ≥2 supporting elements for Low MDM.
3. Moderate MDM
Problem:
- 1 chronic illness not at goal (e.g., diabetes worsening A1C from 7% → 9%) OR
- 2+ chronic issues with worsening (e.g., COPD + CHF with new orthopnea).
Data Reviewed:
- 3+ tests with documented analysis (e.g., “CXR shows new 3cm effusion”) OR
- A discussion with another provider is documented in the note.
Risk:
• Moderate (e.g., new anticoagulant, decision for colonoscopy).
CPT Nuance: “Prescription drug management” includes renewals with dosage adjustments.
4. High MDM
Problem:
- 1 acute life-threatening condition (e.g., “STEMI with 3mm ST elevation”) OR
- 2+ chronic illnesses with end-organ damage (e.g., “ESRD on dialysis + decompensated cirrhosis with ascites”).
Data Reviewed:
- Complex data (e.g., biopsy pathology, genomic testing) +
- Multi-specialty coordination (e.g., “Discussed with oncology and palliative care teams”).
Risk:
- High (e.g., intubation, chemotherapy initiation).
Documentation Tip: Explicitly state risk (e.g., “High mortality risk due to septic shock”).
Key Compliance Considerations
1. Official Guidelines
Always cross-check with:
- CPT E/M Guidelines (e.g., AMA’s definition of “independent interpretation”).
- CMS Manual System, Chapter 12 (for Medicare patients).
Refer to this billing compliance checklist for internists to reduce audit risks.
2. Data Element Nuances
- Each unique test counts once (CBC + diff = 1 test).
- External data counts only if it is not your prior documentation.
| Counts as Data | ✅ | Does NOT Count | ❌ |
|---|---|---|---|
| External provider’s note | ✅ | Your previous progress note | ❌ |
| Pathology report reviewed | ✅ | Test ordered but not reviewed | ❌ |
3. Payer-Specific Rules
| Payer | Key MDM Requirement |
|---|---|
| Medicare | Requires strict “two of three” element matching |
| Medicaid (varies by state) | Often requires problem complexity documentation |
| Commercial | May accept time-based coding alternatively |
4. Risk Documentation
- Avoid: “Low/Moderate/High risk” without justification.
- Use: “Low risk – prescribed terbinafine for onychomycosis (no monitoring needed).”
Comparison Table (Audit-Ready)
| MDM Level | Problem Threshold | Data Threshold | Risk Threshold | Audit Tip |
|---|---|---|---|---|
| Straightforward | 1 minor, self-limiting | None | Minimal | Document expected resolution timeline |
| Low | 2+ minor OR 1 chronic + labs | 1-2 simple data points | Low | Note medication monitoring requirements |
| Moderate | 1 uncontrolled OR 2+ flaring | 3+ analyzed items OR consult | Moderate | Link Rx changes to specific lab results |
| High | Life-threatening OR multi-organ failure | Complex data + team input | High | State mortality risk explicitly |
How incorrect E/M coding leads to denials, see our breakdown of common internal medicine billing errors.
Important Note: This guide provides a framework for MDM coding, but always verify decisions against current CPT guidelines and payer-specific policies. Consult your organization’s compliance officer or the AMA’s latest E/M documentation guide for authoritative clarification when in doubt.
What Are the Time Thresholds for Office Visit E/M Codes?
In 2025, office/outpatient E/M codes 99202–99215 continue to use minimum time thresholds (met or exceeded), not time ranges.
| CPT Code | Time (Minimum Met/Exceeded) | MDM Level |
|---|---|---|
| 99202 | 15 minutes | Straightforward |
| 99203 | 30 minutes | Low |
| 99204 | 45 minutes | Moderate |
| 99205 | 60 minutes | High |
| 99212 | 10 minutes | Straightforward |
| 99213 | 20 minutes | Low |
| 99214 | 30 minutes | Moderate |
| 99215 | 40 minutes | High |
Key Notes for Internists (and All Providers)
- Time-based coding is allowed if the total time (face-to-face + non-face-to-face work) meets or exceeds the threshold.
- No >50% counseling rule: Since 2021, the requirement that >50% of the visit must be counseling/coordination no longer applies for office visits (99202–99215).
- Choose MDM or Time: The code selection can be based on either the MDM level or the total time (whichever supports a higher level).
- Documentation must reflect the total time if coding by time.
Note: Always verify current coding guidelines with the official CPT codebook or CMS guidance as requirements may be updated.
Accurate EHR use can simplify this, learn more about EHR’s role in accurate billing.
When Should Internists Bill Prolonged Services?
Prolonged service codes apply when the total time spent on a patient’s care exceeds the standard duration of the primary evaluation and management (E/M) service by at least 15 minutes.
However, Medicare and private payers follow different rules, so understanding the thresholds and recent updates is critical to avoid claim denials.
Prolonged Service Codes & Thresholds
1. Non-Medicare (CPT 99417)
Used with: 99205 or 99215
Threshold: Total time must exceed the typical time of the base code by at least 15 minutes.
Example (99215):
Typical time = 40 minutes
Prolonged service starts at 55 minutes (40 + 15).
Example (99205):
Typical time = 60 minutes
Prolonged service starts at 75 minutes (60 + 15).
2. Medicare (CPT 99417)
Used with: 99205 or 99215
Threshold: Total time must exceed the maximum time of the base code by at least 15 minutes.
Update:
Medicare no longer uses G2212 for office/outpatient prolonged services. Instead, it follows CPT 99417 but retains the maximum time threshold (unlike non-Medicare payers).
Example (99215):
Maximum time = 54 minutes
Prolonged service starts at 69 minutes (54 + 15).
Note: Medicare continues to use G0316, G0317, and G0318 for prolonged inpatient, nursing facility, and home/residence services, respectively. G2212 remains valid only for inpatient/observation prolonged services.
Key Considerations for Proper Billing
1. Qualifying Time
Total time includes:
- Face-to-face and non-face-to-face time (e.g., chart review, documentation, care coordination).
- Time spent on history, exam, medical decision-making, counseling, and care planning.
Excluded time:
- Time spent on separately billable procedures (e.g., wound closure, injections).
- Time reported under another service (e.g., psychotherapy).
2. Medical Necessity & Documentation
- Must be justified (e.g., “Extended time due to complex medication reconciliation, multiple comorbidities, or caregiver counseling”).
- Avoid vague notes (e.g., “discussed treatment options” without linking to complexity).
- Documentation must reflect total time spent on the same calendar day as the primary E/M service.
3. Payer-Specific Rules
Non-Medicare payers may follow either:
- Typical time + 15 minutes (CPT rules) or
- Maximum time + 15 minutes (Medicare-like).
Always verify payer policies (e.g., Medicaid, commercial insurers).
4. Documentation Best Practices
- Clearly state total time (e.g., “Total visit time: 70 minutes”).
- Specify prolonged activities (e.g., “20 minutes spent on complex care coordination for uncontrolled diabetes”).
- Link prolonged time to medical necessity and complexity.
Medicare scrutinizes 99417 time logs. Learn how to structure your documentation to survive MAC audits.
Final Checklist for Internists
✅ Only bill with highest-level E/M codes (99205/99215).
✅ Medicare now uses 99417 (not G2212) for office/outpatient prolonged services.
✅ G2212 remains valid only for inpatient/observation (Medicare).
✅ CPT 99417 is billed in 15-minute increments (1 unit = first 15 min, +1 unit per additional 15 min).
✅ Time alone isn’t enough- tie to medical necessity.
✅ CPT 99417 cannot be billed for less than 15 additional minutes beyond the threshold and is not reported with psychotherapy codes.
Read our guide on choosing the right billing company to ensure specialized support.
When Can Internists Bill Split/Shared E/M Visits?
For split/shared visits between NPs/PAs and physicians in 2025:
Billing Provider Rules:
- Primary method: Physician must perform more than 50% of the medical decision making (MDM).
- Alternative method (facility settings only): When MDM is equal, the clinician spending more than 50% of the total time (face-to-face and non-face-to-face) bills the visit.
- Critical care exception: Always determined by time spent.
Key Documentation Requirements:
- Must clearly state who performed MDM or spent the majority of time.
- Example: “PA completed history and exam. Dr. Jones reviewed imaging results and finalized the treatment plan (MDM primarily by Dr. Jones). Total time: PA 25 minutes, Dr. Jones 30 minutes.”
Critical Settings Information:
- Applies only to facility settings (hospitals, SNFs, EDs).
- Does not apply to office visits.
- Medicare strictly follows MDM-based determination.
- Some commercial payers may still use time-based rules to verify individual policies.
Compliance Risks:
- Unclear documentation leads to NP/PA billing (lower reimbursement).
- Incorrectly applying to office settings triggers denials.
- Failing to specify MDM ownership risks in audit findings.
Final Checklist for Split/Shared Visits
✅ MDM >50% = Default Rule (document explicitly).
✅ Time >50% = Backup in Facilities CareMDM is equal.
✅ Critical Care = Time Always Wins.
✅ Facility Settings Only (no office visits).
✅ Check Payer Rules (commercial payers may differ).
What Are the Internist-Specific Scenarios for E/M Coding?
Case 1: Stable Chronic Condition (99213)
Clinical Scenario:
- 65-year-old with well-controlled hypertension
- No new symptoms or complications
- Routine blood pressure check
- No new medications or tests ordered
Key Elements:
- Problem Points: 1 stable chronic illness (hypertension)
- Data Reviewed: Minimal (vital signs only)
- Risk: Low (continued prescription management)
- Time: 20 minutes (includes history, exam, documentation)
Final Code: 99213 (Low complexity MDM)
Case 2: Complex Chronic Disease Management (99214)
Clinical Scenario:
- 58-year-old with uncontrolled diabetes (HbA1c 9.2%)
- New neuropathic symptoms in the feet
- Reviewed recent HbA1c/CMP results
- Insulin regimen adjusted
Key Elements:
- Problem Points: 1 uncontrolled chronic illness + new symptom
- Data Reviewed: 2 lab sets (HbA1c trend, CMP)
- Risk: Moderate (insulin titration)
- Time: 35 minutes (includes neuropathic exam, counseling)
Final Code: 99214 (Moderate complexity MDM)
If you’re unsure how E/M coding scenarios differ by specialty, explore the differences between internal medicine and family practice billing.
Case 3: Multisystem Acute/Chronic Care (99215)
Clinical Scenario:
- 72-year-old with CHF exacerbation + CKD stage 3 + new atrial fibrillation
- Reviewed cardiology consult, EKG, and renal function tests
- Adjusted diuretics and anticoagulants due to hyperkalemia
Key Elements:
- Problem Points: 2+ chronic illnesses with exacerbation + new acute condition
- Data Reviewed: EKG, 3+ lab sets, specialist note
- Risk: High (medication changes with monitoring requirements)
- Time: 50 minutes (includes care coordination, family discussion)
Final Code: 99215 (High complexity MDM)
Key Documentation Tips
Link MDM Elements Clearly:
- For 99214+: Show medication changes are tied to lab/imaging results
- For 99215: Document coordination with other providers
Time Tracking:
- Include all activities (e.g., “15 minutes spent counseling on insulin administration”)
Acuity Matters:
- Stable chronic = 99213
- Uncontrolled chronic + new issues = 99214
- Multiple interacting conditions = 99215
2025 Telehealth Billing Rules for Internists
CMS has extended pandemic-era flexibilities with critical coding updates. Master these key changes to avoid denials.
1. Visit Types & Modifiers
Visit Types & Modifiers
Covered Services:
- E/M visits (99202-99215)
- Behavioral health (90832-90837)
Required Modifier: -93 (Medicare mandate)
Excluded: Telephone codes (99441-99443)
Video Visits
- Modifier: -95 (as pre-2025)
- Documentation Must Specify: “Real-time interactive video”
2. Place of Service (POS) Coding
| POS Code | Use When | Example |
|---|---|---|
| 02 | Provider at clinic/hospital | Doctor in office, patient at home |
| 10 | Patient at home | Homebound CHF follow-up |
3. Approved 2025 Telehealth Codes
| Code Range | Service | Key Requirement |
|---|---|---|
| 99202-99215 | Office visits | -93 (audio), -95 (video) |
| 90832-90837 | Therapy | Audio-only requires -93 |
| 99453-99454 | Remote monitoring | Chronic conditions only |
| 98966-98968 | Virtual check-ins | Replaces G2252 |
4. Approved 2025 Telehealth Codes
✅ Service type (audio/video) + duration
✅ Patient consent for telehealth
✅ Medical necessity statement (e.g., “Patient lacks video capability”)
✅ Correct modifier (-93 or -95)
5. Compliance Red Flags
- Denial Risk: Using 99441-99443 for Medicare telehealth
- Modifier Error: Applying -95 to audio-only behavioral health
- Obsolete Code: G2252 (use 98966-98968 instead)
Tips for 2025
- Cross-check codes quarterly against Medicare updates
- Audit 10% of claims monthly for modifier accuracy
- Train staff on the -93/-95 distinction
How to Train Your Staff on Internal Medicine Billing Rules?
Example Scenario:
This was a 55-minute audio-only visit for COPD management with home O2 adjustment. POS 10, modifier -93. The patient’s lack of a smartphone for video was documented.
For complex cases, consult your MAC’s 2025 Telehealth FAQ.
Note: Verifying all details with the relevant payers, specifically CMS and others, is crucial for accurate and compliant billing practices.
Which Modifiers Should Internists Use with E/M Codes?
| Modifier | Use Case | Description |
|---|---|---|
| -25 | E/M + procedure, same day | “Significant, separately identifiable E/M” performed on the same day as a procedure |
| -24 | E/M during global period | “Unrelated E/M service during postoperative period” |
| -95 | Telehealth | “Synchronous telehealth service” (live video) |
| -AI | Hospitalist vs attending | “Principal physician of record” modifier to denote hospitalist billing when attending physician is involved |
Incorrect modifier usage is a top reason for E/M claim denials.
How Can Internists Prevent E/M Coding Errors in 2025?
Audit-Proof Your Notes:
✅ Always justify the MDM level with complexity, data, and risk.
✅ Document total time, including pre- and post-visit tasks.
✅ Identify who owns the MDM in split/shared visits.
✅ Attach proper modifiers for same-day services or telehealth.
✅ Align diagnoses with documentation in the same encounter.
To avoid underpayments and audits, understanding common billing challenges for internists can help strengthen compliance protocols.
Implement external billing audits and reviews for better compliance oversight.
Common Pitfall to Avoid:
Notes stating “stable, no changes” without elaborating on MDM details often lead to downcoding or claim denials because they fail to support the billed service level.
Refer to our complete internal medicine billing guide for more strategies to optimize reimbursement and documentation.
Frequently Asked Questions (FAQ’s)
What are the significant E/M coding changes in 2025 for internists?
MDM is now the main factor for code selection. Time thresholds are adjusted, and rules for prolonged services, split/shared visits, and telehealth billing are updated.
Can internists still use time-based coding in 2025?
Yes, internists can code by time if the total time is documented and meets the minimum required for the E/M code.
What time is required to bill 99214 in 2025?
99214 requires a minimum of 30 minutes of total time spent on the same calendar day.
When should CPT 99417 be used for prolonged services?
Use CPT 99417 when the total visit time exceeds 99205 or 99215 by at least 15 minutes.
Can internists bill prolonged services with 99213 or 99214?
No, prolonged services apply only to 99205 and 99215 for outpatient visits.
What does “more than 50% of MDM” mean for split/shared billing?
The billing provider must make most medical decisions documented in the patient notes.
Can internists bill audio-only telehealth visits in 2025?
Medicare permits audio-only telehealth visits for select services such as behavioral health and certain E/M visits, and modifier -93 must be used.
What is the difference between POS 02 and POS 10 in telehealth billing?
POS 02 is used when the patient is not home; POS 10 is for home-based visits.
Which modifiers are commonly used with internist E/M codes?
Modifiers -25, -24, -95, and -AI are frequently used based on encounter type and setting.
What documentation is required for MDM-based E/M coding?
You must document problem complexity, data reviewed, and risk factors to support the selected MDM level.
How does Medicare differ from commercial payers for prolonged services?
Medicare requires a prolonged time to exceed the maximum base time for the code. At the same time, CPT guidelines use the typical time for the service.
What are examples of high-complexity MDM conditions?
Examples include STEMI, decompensated cirrhosis, and multi-organ failure with active risk of mortality.
What is the required time to bill CPT 99417 for Medicare?
For 99215, time must exceed 54 minutes to qualify for Medicare prolonged billing with CPT 99417.
How can internists reduce E/M coding denials?
Document MDM, verify time thresholds, use correct modifiers, and align billing codes with clinical notes.
Understand the difference between billing and coding to avoid documentation mismatches.
Understand common reasons for billing denials to protect revenue.
