Internal Medicine, coding reference.

Use 99213 for a stable established outpatient with one or two minor or stable problems, simple data review, and low-risk management. Typical patterns: routine refill of a stable chronic medication, follow-up on a single well-controlled chronic disease, simple URI evaluation, or a stable hypertension recheck with no medication change. The 2021 MDM rubric requires low complexity on two of three elements (Problems Addressed, Data Reviewed, Risk). Time-based alternative is 20 to 29 minutes of total physician or QHP time on the date of the encounter. Pick the method that supports the strongest note: if the encounter clearly reflects low-complexity MDM, code by MDM and skip a time statement. Avoid the temptation to inflate to 99214 without a moderate-complexity MDM element.

99214 is the workhorse of primary care and most outpatient subspecialties. Use it when at least one of these is true: two or more chronic problems with progression, treatment changes, or side effects; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; or prescription drug management at any complexity. Prescription drug management on its own satisfies the moderate-risk element, which is why straightforward chronic disease follow-ups with a med adjustment routinely clear the 99214 bar. Time-based alternative is 30 to 39 minutes of total time on the date of the encounter. Pick the method that supports the strongest note: encounters with prescription changes are usually cleaner under MDM; encounters with extensive counseling or care coordination are usually cleaner under time.

Select this level when at least two of the three MDM elements meet high complexity, or when qualifying total time reaches 40 minutes. A diagnosis, medication, or high-risk decision alone does not establish the overall level. For Medicare prolonged services with this time-selected base code, the first G2212 unit requires 69 minutes. Payers recognizing CPT 99417 use different thresholds.

99204 is the default code for most new-patient outpatient encounters in primary care and outpatient subspecialty practice. Use it for a new patient with at least one of: two or more chronic problems with progression or treatment changes; one undiagnosed new problem with uncertain prognosis; prescription drug management. Common patterns: new patient establishing primary care with multiple chronic comorbidities; new endocrinology consult for poorly controlled T2DM; new cardiology consult for chest pain and an abnormal stress test result. Prescription drug management satisfies moderate risk on its own, which makes 99204 the right code for the vast majority of new-patient continuity encounters. Time-based alternative is 45 to 59 minutes of total time on the date of the encounter.

Select this level when at least two of the three MDM elements meet high complexity, or when qualifying total time reaches 60 minutes. A diagnosis, medication, or high-risk decision alone does not establish the overall level. For Medicare prolonged services with this time-selected base code, the first G2212 unit requires 89 minutes. Payers recognizing CPT 99417 use different thresholds.

Consider the ongoing responsibility for the patient's care: either a continuing focal point for needed services or ongoing care of a serious or complex condition. It is not automatic for a diagnosis or specialty.

99497 captures the time spent in a structured conversation about advance directives, healthcare proxy designation, code status, MOLST or POLST forms, hospice eligibility, and goals of care. The patient must be present at the start of the conversation unless the entire visit is with a designated surrogate (which is independently billable but requires explicit documentation). Common scenarios: ACP as a same-day add-on to an AWV (cost-share is waived with modifier 33); ACP at a primary-care continuity visit for a patient with advanced chronic disease; ACP at an oncology visit for a patient at end of treatment options; ACP during a geriatric assessment.

Use G0444 for an eligible Medicare annual depression screening. Confirm the current coverage, frequency, setting, and documentation requirements, including any same-day bundling rules. Do not substitute AWV eligibility for depression-screening eligibility.

G0537 captures an annual ASCVD risk calculation plus counseling for patients without established atherosclerotic cardiovascular disease. Use the ACC/AHA Pooled Cohort Equations (PCE) or an equivalent validated tool to compute the 10-year ASCVD risk percentage. The code is for primary prevention only: patients with known coronary artery disease, prior MI, prior stroke, peripheral artery disease, or any documented ASCVD do not qualify. Most natural pairing is with G0438 or G0439 (AWV), but G0537 can also be billed at a problem-oriented visit. Counseling must address one or more modifiable risk factors: hypertension, dyslipidemia, smoking, diabetes, weight, physical activity, or diet. Once per 12 months. ICD-10: Z13.6 (cardiovascular disorder screening). G0538 is the same-day add-on for additional 15-minute increments of high-intensity behavioral counseling (rarely used in primary care; more relevant in cardiology or weight-management practices).

Use 99406 for any encounter where you spent 3 to 10 minutes counseling a current tobacco user on cessation. The 5 A's framework (Ask, Advise, Assess, Assist, Arrange) is the documentation backbone; you do not need all five at every visit but document the ones that occurred. Common settings: a hypertensive smoker at a primary-care follow-up where you advised cessation and discussed pharmacotherapy options; a COPD patient at a pulmonology visit where you assessed readiness and prescribed varenicline; a cardiac patient post-MI where you arranged a referral to a state quitline. The patient must be a current tobacco user (not former). For relapse prevention in an ex-smoker, the work is part of the E/M and is not separately billable as 99406. Time must be documented separately from E/M time; if your E/M counted time toward the 30 to 39 minute 99214 threshold, you cannot also count the cessation minutes toward 99406. The time must be carved out.