Medical Coding — CPT Structure & E/M flashcards
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CPT categories I, II and III, the six sections, guidelines, unlisted codes and symbols, then E/M: new versus established patients, MDM and time since 2021 and 2023, consultations, critical care, prolonged and preventive services. No CPT descriptors reproduced.
Learn deck · part of Medical coding: AAPC CPC and AHIMA CCA · written against: ICD-10-CM Official Guidelines and code set FY 2027 (effective 1 October 2026); CPT structure and E/M guidelines described in our own words; HCPCS Level II, NCCI and ICD-10-PCS per CMS. Updated 2026-10-10.
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Who maintains the CPT code set, and when does its main annual update take effect?The American Medical Association, through its CPT Editorial Panel; the annual release takes effect on 1 January.CPT Structure › Categories and Sections
CPT is Level I of HCPCS, while CMS maintains the Level II national codes. -
Which core requirements must a service meet to receive a Category I CPT code?FDA clearance or approval where required, performance by many practitioners across the country, and documented clinical efficacy.CPT Structure › Categories and Sections
The CPT Editorial Panel also looks for use often enough for its intended purpose and consistency with current practice; a service that does not yet meet these tests may be given a Category III code instead. -
How is a Category II CPT code formatted, and what is it for?Four digits followed by F; it is an optional tracking code for performance measurement.CPT Structure › Categories and Sections
Category II codes supplement Category I codes and never replace them. -
What do the Category II modifiers 1P, 2P and 3P indicate?Why a performance measure was not met: 1P for medical reasons, 2P for patient reasons, 3P for system reasons.CPT Structure › Categories and Sections
Watch out: 8P reports that the action was not performed, for a reason not otherwise specified. -
How is a Category III CPT code formatted, and when is it used instead of an unlisted Category I code?Four digits followed by T, for emerging technology; when one describes the service, it is reported instead of an unlisted code.CPT Structure › Categories and Sections
Category III codes are temporary and may later become Category I codes or be retired. -
When is a patient "new" rather than "established" for E/M reporting?When the patient has had no professional services in the past three years from the physician or another physician of the exact same specialty and subspecialty in the same group.Evaluation and Management › Patient Status
A visit to a different specialty in the same group does not make the patient established. -
A physician covers for a colleague who is away. How is the colleague's patient classified?As the absent physician would have classified the patient, new or established.Evaluation and Management › Patient Status
Covering for a colleague does not turn an established patient into a new one. -
A nurse practitioner in a cardiology group saw the patient last year, and the patient now sees a cardiologist in the group. New or established?Established: an NP or PA working with physicians counts as the same specialty and subspecialty as those physicians.Evaluation and Management › Patient Status
The earlier visit therefore falls within the three-year rule. -
A physician interpreted a patient's ECG last month without ever seeing the patient. When the patient now visits that physician, can the visit be a new patient visit?Yes, if there was no other professional service in three years: interpreting a test without an E/M or other face-to-face service does not affect new patient status.Evaluation and Management › Patient Status
New patient status turns on professional services such as visits, not on test readings alone. -
Since 2021, how is the level of an office or outpatient visit selected?By medical decision making or total time on the date of the encounter, whichever of the two the clinician uses to select the level; history and examination no longer set the level.Evaluation and Management › Decision Making and Time
Why: history and examination are performed as medically appropriate, and the 2023 revision extended the MDM-or-time choice to most other E/M categories, while emergency department visits are leveled by MDM only.
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About these cards
Review status: Second-reader reviewed, with corrections applied.
Checked against:
- CPT® is a registered trademark of the American Medical Association. No CPT descriptors are reproduced; CPT structure and guidelines are described in our own words.
- HCPCS Level II codes and Medicare E/M policies checked against CMS publications (public domain).
- CPC® is a registered trademark of AAPC, and CCA is a credential of AHIMA; neither is affiliated with, or endorses, this product.
- CPT content checked in October 2026 against the AMA's published CPT pages and E/M guideline documents and against CMS publications that reproduce CPT (MLN006764, Medicare Claims Processing Manual ch. 12, NCCI Policy Manual 2026), not against the CPT 2026 Professional Edition.
These are independent study notes written for Willys. They are not official exam material, may contain mistakes, and are no substitute for your course, your teacher or the exam owner's own publications. Found an error? Tell us — corrections ship as a new version of the deck.
Not coding, billing or compliance advice. These cards prepare you for a certification exam. Code sets change every year, so code real claims from the current ICD-10-CM, CPT® and HCPCS books and your payers' policies. No CPT descriptors are reproduced here.
CPT® is a registered trademark of the American Medical Association; no CPT descriptors are reproduced. CPC® is a registered trademark of AAPC, and CCA is a credential of AHIMA; neither is affiliated with, or endorses, this product.
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