Evaluation and management level selection

When the level billed for an office or outpatient visit is supported by the record, and what the record has to contain to support it.

All policies

Current version

v4.2

in force since 2026-01-01 · as at 2026-04-02

Versions on file

back to 2023-10-01

Applies to

All lines of business

All states

Cited in this batch

claims tested against it

Where this sits

OwnerPayment Integrity Policy Committee

Lines of businessAll lines of business

StatesAll states

External basisCPT E/M guidelines · CMS Claims Processing Manual ch. 12 §30.6

Version history

Newest first

A claim is tested against the version that was in force on its date of service. For a service last autumn, that is not the version at the top of this list.

v4.2 2026-01-01 → current In force now

Time-based selection now requires total practitioner time recorded on the date of the encounter. Preventive-only diagnoses no longer support a level 4 or 5 problem-oriented visit on their own.

Extracted from CPP-014_em-level-selection_v4.2.md — 3 pages, indexed under __live__, so a finding on this version can quote it.

Level 5 (99205 / 99215) requires high-complexity medical decision making, or documented total time in the code's range.
A routine examination diagnosis without a documented problem addressed does not by itself support a level 4 or 5.
Where the record supports a lower level, the claim is repriced to that level rather than denied in full.

v4.1 2025-01-01 → 2025-12-31 Superseded

Annual refresh against the 2025 CPT revisions. No change to level-5 documentation requirements.

No source document in the index. A finding on this version can cite it by name but cannot quote a passage.

Level 5 requires high-complexity medical decision making, or documented total time in the code's range.
Where the record supports a lower level, the claim is repriced to that level.

v3.0 2023-10-01 → 2024-12-31 Superseded

Adopted the 2021 office-visit framework: history and examination no longer drive level selection.

No source document in the index. A finding on this version can cite it by name but cannot quote a passage.

Level selection is driven by medical decision making or total time.

Claims in this batch tested against this policy

3 of 25

Claim	Date of service	Version applied	Role	Paid	At risk
CLM-0000001	25 Mar 2026	v4.2	Decisive	$4,280.00	$4,089.23
CLM-0000002	04 Mar 2026	v4.2	Supporting	$94.22	—
CLM-0000005	27 Mar 2026	v4.2	Supporting	$133.60	—

This policy is synthetic — an internal document written for this demo. The external basis it cites is real.