In simple words: This code is used for a visit with a doctor or other healthcare professional when you are a new patient to that provider. The visit includes discussion of your medical history, a physical exam (if needed), and simple medical decision-making. For this code to be used, the total time the healthcare professional spends on your care that day must be 15 minutes or longer.

This code represents an evaluation and management service provided to a new patient in an office or other outpatient setting.It involves a medically appropriate history and/or physical examination, along with straightforward medical decision making.To select this code based on time, the total time spent on the date of the encounter must be 15 minutes or greater. "Total time" encompasses all activities performed by the physician or other qualified healthcare professional on the day of the encounter related to the patient's care, both face-to-face and non-face-to-face.Examples of these activities include:reviewing prior tests, preparing for the visit, obtaining and reviewing the patient's history, performing the examination or evaluation, counseling and educating the patient/family/caregiver, ordering medications, tests, or procedures, communicating with other healthcare professionals, documenting the encounter in the medical record, independently interpreting results and communicating them to the patient/family/caregiver, and coordinating care.The level of medical decision making for this code is “straightforward,” which signifies a lower complexity of medical decision making.

Example 1: A new patient presents to a family physician with a complaint of a sore throat.The physician takes a history, performs a physical exam, and determines the patient has strep throat.The physician prescribes an antibiotic and provides education on how to take the medication.The total time spent on the encounter is 20 minutes., A new patient visits a psychiatrist for an initial evaluation. The psychiatrist obtains a detailed history of the patient’s presenting problem, including a review of past psychiatric history and family history. The psychiatrist performs a mental status examination.The total time spent is 25 minutes. The psychiatrist makes a preliminary diagnosis of major depressive disorder and discusses treatment options with the patient., A new patient visits a dermatologist with a new mole.The physician examines the mole and determines a biopsy is needed to evaluate for skin cancer. The total time for the visit is 18 minutes.The biopsy is scheduled.

Documentation should support the level of history, examination, and medical decision making performed. The total time spent on the date of the encounter should also be documented if using time for code selection.The documentation should reflect the nature of the presenting problem(s), the rationale for the services provided, and the complexity of the medical decision-making process.