CPP-014_em-level-selection_v4.2.md

# CPP-014 — Evaluation and management level selection **Version 4.2 · Effective 1 January 2026 · Supersedes v4.1** Owner: Payment Integrity Policy Committee Applies to: All lines of business — all states External basis: CPT E/M guidelines · CMS Claims Processing Manual ch. 12 §30.6 ## 1. Purpose 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. ## 2. What changed in version 4.2 Two changes take effect on 1 January 2026: 1. Time-based selection now requires total practitioner time recorded on the date of the encounter. A range, an estimate, or a time recorded on a different date does not support selection by time. 2. A preventive-only diagnosis no longer supports a level 4 or level 5 problem-oriented visit on its own.

## 3. Criteria ### 3.1 Level selection Level is selected by medical decision making or by total time on the date of the encounter. History and examination do not drive level selection. Level 5 for an established patient (99215) requires high-complexity medical decision making, or documented total time in the range published for the code. ### 3.2 Preventive diagnoses A routine examination diagnosis — the Z00 series — describes an encounter without a presenting problem. It does not by itself support the moderate or high complexity that a level 4 or level 5 problem-oriented visit requires. Where a problem was addressed at a preventive visit, the record must show the problem, the data reviewed, and the risk considered. ### 3.3 Repricing rather than denial Where the record supports a lower level than the one billed, the claim is repriced to the level the record supports. It is not denied in full. The recoverable amount is the difference between the allowable for the billed level and

wer level than the one billed, the claim is repriced to the level the record supports. It is not denied in full. The recoverable amount is the difference between the allowable for the billed level and the allowable for the supported level. This is the payer-side counterpart of up-coding: the remedy for a level billed above the record is a down-code to the level the record carries, not a refusal to pay for a visit that happened.

## 4. Recovery recovery = allowable(billed level) - allowable(supported level) Both allowables come from the fee schedule in effect for the locality on the date of service. Where the amount paid exceeded the allowable for the billed level, the excess above the allowable is recoverable in addition, and is a pricing finding rather than a coding one. The two are reported separately on the notice. ## 5. Provider dispute A provider disputing a finding under this policy may submit the encounter note for the date of service. Where the note documents the decision making or the total time the billed level requires, the finding is withdrawn.