Walk through a general practice clinic at the end of a busy day and the same quiet question sits behind the billing screen: was that a 99203 or a 99213? The consultation itself may have taken twenty minutes. Choosing the code that describes it, and that a payer will accept without a query, can take far longer if the clinic has no shared rules.

This article walks through how Evaluation and Management (E/M) codes work for office and outpatient general practice visits, how to separate new patients from established ones, and how the complexity of a visit moves the code up or down. It also looks at what Dubai’s published billing rules show about how regulators think, and what is publicly known about the Northern Emirates, where claims run through a different platform.

Why E/M coding deserves its own attention

E/M codes are the workhorse of general practice. Most visits in a GP clinic are some combination of history, examination, assessment and a plan, and that is exactly what E/M codes describe. Procedures, labs and imaging come and go, but the consultation is present in almost every claim.

That frequency is why small errors compound. A clinic that habitually selects one level too high invites payer audits and recoupment. A clinic that habitually selects one level too low gives away revenue it earned, and it does so silently, because underpayment rarely triggers an alert. Both patterns usually start the same way: no one has agreed on what separates one level from the next.

Two terms matter before anything else. The first is the patient status, meaning new or established. The second is the level, meaning how much work the visit involved. Status chooses the code family. Level chooses the code within that family.

Step one: is the patient new or established?

Under CPT conventions, a new patient is one who has not received any professional service from the physician, or from another physician of the exact same specialty and subspecialty in the same group practice, within the previous three years. An established patient has. The test is about the clinician or group and the specialty, not about whether the person has walked through the front door before.

Three practical consequences follow for a general practice:

• The clinic is the group. If a patient saw Dr. A in your clinic eighteen months ago and now books with Dr. B, also a general practitioner in the same practice, the patient is established for Dr. B.
• Specialty matters. A patient who has only seen your dermatologist may still be new to your general practitioner, because the specialties differ.
• Branches need shared history. For multi-branch groups, the status check only works if the system can see visits across branches. Two separate patient files for the same person will quietly produce new patient codes that a payer’s own history will contradict.

The new patient family runs from 99202 to 99205. The established family runs from 99212 to 99215, plus 99211, which describes a minimal visit that may not require a physician and cannot be selected by time. Notice that new patient codes start at 99202, not 99201, which CPT deleted in 2021.

What Dubai’s published rules illustrate about consultation billing

A useful way to see how a regulator thinks about consultation billing is the Dubai Health Authority’s Dubai Standards of Care (2019) for dental billing, which applies to the Dubai government health insurance programs, SAADA and ENAYA. It is a dental document built on CDT codes rather than CPT, so it does not set GP E/M rules, and we are not presenting it as one. But its consultation provisions show the logic that Dubai adjudication tends to follow, and general practices can learn from it.

Four ideas stand out:

• A defined window turns later visits into follow-ups. The document covers a consultation or oral evaluation by the same dentist for a period of three months. Visits after the first within that window are follow-ups that are neither claimed from the program nor charged to the patient. The lesson for GPs is that payers often define a window around an initial visit, and the window, not the clinician’s description of the visit, decides whether a new consultation can be billed.
• The consultation is absorbed when treatment happens the same day. No separate consultation is billed if the dentist performs a procedure at the same visit, and the procedure fee is expected to include the consultation. The GP parallel is the visit where a procedure is done on the same day. Whether a separate E/M is billable depends on the payer’s rules and on whether the evaluation was significant and separate from the procedure.
• Documentation is the condition of payment. The rules require a complete health record: history, chief complaint, diagnosis, treatment plan and treatment done, with accurate dates. Payment depends on that record existing in the clinic’s files.
• A disallowed fee is not the patient’s to pay. The introduction states that when a fee is disallowed it is not payable by the program and cannot be collected from the patient. A denial caused by a coding error is therefore the clinic’s loss, not something to pass on.

The document also notes that the codes it lists are not all included in the SAADA and ENAYA programs, and that the existing table of benefits clauses prevail if any contradiction exists. That is a reminder that a code being valid in CPT does not make it payable. Always check the payer’s active tariff and plan terms.

Step two: choose the level by medical decision making or by time

Since the 2021 revision of the office and outpatient E/M codes, CPT lets the clinician pick the level on either of two bases: the medical decision making (MDM) involved, or the total time spent on the date of the encounter. The old reliance on history and examination as scoring components was dropped. History and examination still have to be “medically appropriate”, but they no longer count toward the level.

Level	New patient	Established patient	MDM level	Minimum total time (new / established)
1	—	99211	Minimal; may not need a physician	Time not used
2	99202	99212	Straightforward	15 / 10 minutes
3	99203	99213	Low	30 / 20 minutes
4	99204	99214	Moderate	45 / 30 minutes
5	99205	99215	High	60 / 40 minutes

Older materials show time as ranges, such as 30 to 44 minutes for 99203. The 2024 revision of the descriptors changed the wording to say the stated number of minutes must be met or exceeded. The practical effect is the same, since you still cannot reach a level without its minimum, but it removes the argument about upper limits.

How visit complexity moves the code

MDM is assessed on three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed and analysed, and the risk of complications from patient management. The level is the one that at least two of the three elements support. A visit that is strong on one element and weak on two is coded to the weaker level.

Problems addressed

This element asks what the clinician actually evaluated or managed. At the low end sit a single self-limited problem such as a mild cold (straightforward) and slightly more, such as two minor problems, one stable chronic illness or one acute uncomplicated illness (low). Moderate territory includes a chronic condition that is not at goal or is worsening, two or more stable chronic conditions, a new problem whose cause is uncertain, or an acute illness with systemic symptoms. High territory involves a severe exacerbation of a chronic illness, or a condition that threatens life or bodily function. A problem is counted by what the clinician addresses, not by what the patient mentions.

Data reviewed and analysed

Data covers tests ordered or reviewed, external notes reviewed, history obtained from an independent historian, and independent interpretation of a test. The weight comes from variety and from analysis. A single ordered test is a limited amount of data. Several tests, plus outside records and discussion with another clinician, push the visit toward moderate or extensive. Ordering a test and later reviewing its result are counted together, so clinics should not claim the same data twice.

Risk of management

Risk reflects what could go wrong with the plan. Over-the-counter advice and rest sit at low risk. Prescription drug management is the usual marker for moderate risk, which is why a visit to adjust a blood pressure or diabetes medication frequently supports a level four even when the problem is not dramatic. A decision about hospitalisation, or therapy that requires intensive monitoring, supports high risk.

Putting it together in a GP clinic

• An established patient with a sore throat, a quick examination and advice supports a straightforward or low level, 99212 or 99213.
• An established patient with stable hypertension on current treatment, reviewing home readings and continuing medication, typically sits at low to moderate, depending on whether the prescription was actively managed.
• A new patient with a persistent cough of uncertain cause, a chest X-ray and bloods ordered, and a prescription started, supports a moderate level, 99204, because there is a new undiagnosed problem, several data points and prescription management.
• A patient whose chest pain leads to a decision to send them to hospital is the textbook high risk decision, supporting 99205 or 99215.

The key discipline: code the work that was documented, not the diagnosis on the problem list. A long chronic disease history does not raise the level unless it was addressed during that visit.

Using time instead

Time is attractive when a visit is dominated by counselling, coordination or explanation, because those activities may not produce many MDM points but still consume the clinician’s day. The rules are stricter than many clinics expect.

• Total time on the date of the encounter counts, including face to face and non face to face activity by the billing clinician: reviewing records before the visit, examining, counselling, ordering, documenting and communicating results.
• Only the billing clinician’s time counts. Time spent by nurses or other clinical staff is excluded, and when two clinicians see the patient jointly, their time is not added together.
• It must be the same date. Work done the day before or after the visit does not count toward that visit.
• A time statement is essential. A short line in the note stating total time and the activities included is the difference between a defensible level and an assumption.
• Time cannot rescue a visit that did not meet the status requirement. A new patient seen for twelve minutes remains a new patient, so the clinic falls back on MDM rather than switching to an established code.

CPT also provides an add-on code, 99417, for time beyond the minimum for the highest level. Whether it exists in a given payer’s tariff, and in which form, is a payer question to settle before using it, because local price lists do not always mirror the full CPT set.

When both bases are available, choose the one that the record supports more clearly. Never use whichever gives the higher level without evidence. A note that supports a lower level on both bases is a lower level visit.

Documentation that holds up

Good documentation does not mean long notes. It means notes that let a reviewer, who was not in the room, reach the same level you did. For each E/M claim the record should show:

• the reason for the visit and a medically appropriate history and examination;
• each problem addressed and the clinician’s assessment of it;
• tests ordered, results reviewed and outside records considered;
• the management decision, including prescriptions started, changed or continued, and referrals;
• a time statement where time is the basis for the code;
• the date, so the visit can be placed correctly against any follow-up window.

Copy-forward notes are the most common weakness. When a note repeats earlier text word for word, a reviewer cannot tell what was actually done at this visit, and the level it supports collapses to what is new.

One country, three rulebooks

CPT is the common code set, but the rules around it differ by regulator. Dubai claims run through the DHA’s eClaimLink and DHPO environment. Abu Dhabi runs through the Department of Health’s Shafafiya platform. In the Northern Emirates, claims run through the Ministry of Health and Prevention’s e-Claims Post Office on the Riayati platform.

Abu Dhabi’s published adjudication addenda show how specific payer-side rules can become. They address how E/M visits that follow an earlier visit within a set number of days are treated, with modifiers that signal certain circumstances. Those addenda are older and clinics should always read the current version, but they show the kind of rule a GP may meet: follow-up windows, modifier requirements and bundling.

For the Northern Emirates, MOHAP describes the e-Claims Post Office as a unified portal for eligibility checks, authorisation requests, e-prescriptions and claim submissions between providers and payers, using standardised code sets and transaction schemas. A 2022 MOHAP update reported more than 40 insurers and over 1,000 facilities connected. The platform standardises how claims travel. In our research we did not find a public, E/M specific adjudication document for the Northern Emirates comparable to Dubai’s published standards. In practice, the rules a Northern Emirates clinic meets on E/M visits come from the individual payer or third party administrator contract, the plan’s table of benefits and the active tariff.

There is also a policy backdrop. Mandatory basic health insurance for private sector and domestic workers has been rolled out across the Northern Emirates, and the President ordered a national health insurance system for citizens in May 2026. Clinics operating across emirates should avoid assuming that a rule learned in one transfers to another.

Where E/M claims most often go wrong

• New patient code on a returning patient, usually because of duplicate records or a second branch.
• A consultation billed on top of a same day procedure where the payer expects the evaluation to be included.
• Follow-up visits billed as new consultations inside a payer’s follow-up window.
• Level inflation by habit, where every visit becomes a level four.
• Time claimed with no time statement, or with staff time included.
• Codes absent from the payer’s tariff, or services submitted without prior approval where the plan requires it.

A short checklist for your coding routine

• Check visit history across all branches and the three year, same specialty test before selecting a code family.
• Decide the level by MDM or time, and record which basis was used.
• Confirm the code and any frequency limits against the payer’s current tariff.
• Check whether a follow-up window or same day procedure rule applies.
• Confirm that prior approval was obtained where the plan requires it.
• Review the note: could an outside reviewer reach the same level?

Keeping the pieces in one place. 

A clinic management system that holds visit history, structured notes and claim data together makes these checks routine rather than heroic. If you would like to see how Balsam Medico handles patient records and claim workflows for UAE clinics, we would be glad to show you.

Connect with Us

Ready to embark on this exciting journey? Contact us today: 

📍 Dubai, United Arab Emirates – Tel: +971 56 640 9602 

📍 Khartoum, Sudan – Tel: +249 91 273 1048

Explore Balsam Medico and discover a world of efficient clinic management at www.balsammedico.com. Together, let’s reduce fines, elevate efficiency, and embrace a new era of dental healthcare.