• Coding for Evaluation & Management Services

    Evaluation and management (E/M) codes are at the core of most family physician practices. Family physicians and other qualified health professionals can maximize payment and reduce the stress associated with audits by understanding how to properly document and code for E/M services.

    Evaluation and management services are a category of CPT codes and are used for billing purposes. The majority of patient visits require an E/M code. There are different levels of E/M codes which are determined by the complexity of a patient visit and documentation requirements.

    Changes Coming in 2021

    In response to advocacy from the AAFP and other medical specialty societies, CMS has revised the E/M documentation and coding guidelines, with changes beginning January 1, 2021. These fundamental changes (www.ama-assn.org) are intended to reduce administrative burden and increase the amount of time physicians spend caring for patients. CMS will also increase the relative values for office visit E/M codes.

    Use the AMA's CPT E/M Office Revisions: Level of Medical Decision Making (MDM) Table as a guide to select the level of medical decision making for reporting an office or other outpatient E/M service code.

    Though the changes don't go into effect until 2021, practices should begin preparing now. Here are highlights of key changes being implemented.

    History and physical exam codes eliminated (when not appropriate): The patient history and physical exam elements will no longer be components of E/M level code selection. These elements may still be required in relationship to malpractice and quality measures. An understanding of all external documentation guidelines will be necessary before excluding these elements.

    99201 is no longer a valide code: CPT code 99201 will be deleted and will no longer be available as a CPT code selection.

    1995/1997 guidelines will be replaced by medical decision making (MDM) or total time: The 1995 and 1997 guidelines will no longer apply. Physicians will have the option to select the level of visit using either total time or medical decision making (MDM).  The definition of total time in CPT code selection is expanded to include all time (both face-to-face and non-face-to-face) spent in care of the patient on the day of the encounter. The elements of MDM have been updated. See below for more details on selecting E/M codes by total time or MDM.

    Selecting E/M codes by total time - Total time may be used alone to select the appropriate code level for the office or other outpatient E/M services codes (99202-99205, 99212-99215). Total time is the cumulative amount of time spent in care of the patient on the date of the encounter, inclusive of face-to-face and non-face-to-face time spent by the physician and/or other qualified health care professionals. It includes activities such as review of tests; obtaining and/or reviewing separately obtained history; ordering medications, tests or procedures; documentation of clinical information in the electronic health record (EHR) or other records; and communication with the patient, family, and/or caregiver(s).

    Selecting E/M codes by MDM - MDM is the reflection of complexity in establishing a diagnosis, assessing the status of a condition and/or selecting a management option. The table below outlines the levels and elements of MDM.

    CPT Codes Levels of MDM Number and complexity
    of problems addressed
    Amount and/or complexity of
    data to be reviewed and analyzed
    Risk of complications and/or
    morbidity or mortality
    99202, 99212 Straightforward Minimal Minimal or None Minimal
    99203, 99213 Low Low Limited Low
    99204, 99214 Moderate Moderate Moderate Moderate
    99205, 99215 High High Extensive High



    Get Started with These Resources:  2021 Office Visit Evaluation and Management Documentation Changes: 

    The following resources are available to AAFP members. Click to log in and access.

    1. A Checklist for Solo and Independent Physicians - This checklist is designed specifically to help small, solo, and independent practices understand steps to take throughout 2020 to ensure readiness in 2021. The AAFP will provide additional resources to help you with the checklist.
    2. A Checklist for Employed Physicians - This Checklist offers steps employed physicians can take to better understand their employer's training plan and ensure that their employment contracts are updated appropriately.
    3. Practice Training Outline - This sample training outline will help your practice implement the updated E/M guidelines. Use it as a guide to ensure you and your staff understand the key concepts and documentation changes.
    4. Questions to Ask Your Vendors - The updated documentation guidelines will affect multiple aspects of a practice, including your EHR. The AAFP has developed a set of important questions to help you gather key information on your vendor's plans.
    5. Questions to Ask Your Payers - Use this resource as a guide for conversations with your payers.  Practices will need to understand the impact on their contracts, as well as what training/support the payer plans to offer. 
    6. Template Payer Letter - The AAFP will continue to advocate for uniform adoption of changes across all payers, and you can help by contacting the payers you work with. Use this template to send a letter to private payers to encourage them to adopt the same payment policy changes for E/M codes.
    7. Talking Points for Employed Physicians - Use this resource to determine if you should have a conversation with your administrator about how the revaluation of codes will impact your pay, or if a contract amendment is appropriate for you. 
    8. New! 2021 Office Visit E/M Vignettes Module - This resource will allow you to practice coding various scenarios using the new guidelines.
    9. COMING SOON - Guidelines and Vignettes Module - This resource will walk you through the new guidelines and allow you to practice coding various scenarios using the new guidelines.

    Family Medicine Practice Hack Video - E/M Coding

    This Practice Hack video will share how you can use the resources above to prepare for the E/M coding changes that start January 1, 2021.

    Stay tuned for additional videos in the Practice Hack series that will provide you with tips and tricks to help you more easily manage your practice.

        Basic Components of E/M Codes

    • Chief complaint (CC) – Purpose for the patient encounter, typically in the patient’s own words (e.g., "patient complains of upset stomach")
    • History of present illness (HPI) – Description of the CC to include:
      • Location
      • Duration
      • Severity
      • Context
      • Quality
      • Timing
      • Modifying factors
      • Associated signs and symptoms
    • Review of symptoms (ROS) – ROS is an inventory taken from the patient through questions for recognizing symptoms the patient currently has or has had in body systems to include:
      • Constitutional (e.g., vital signs, general appearance)
      • Eyes
      • Ears, nose, throat
      • Cardiovascular
      • Respiratory
      • Gastrointestinal
      • Genitourinary
      • Musculoskeletal
      • Integumentary (skin/breast)
      • Neurological
      • Psychiatric
      • Endocrine
      • Hematologic/Lymphatic
      • Allergic/Immunologic
    • Past, family, social history (PFSH)
      • Past - Previous illness, operations, injuries, and treatments
      • Family - Family history that may place the patient at risk, including medical events, diseases, and hereditary conditions
      • Social - Age appropriate review of patient activities (e.g. substance use, living arrangements, sexual history, employment, education, etc.)
    • Examination - The levels of E/M services are based on four types of examinations:
      • Problem focused - Limited examination of the affected body area or organ system
      • Expanded problem focused - Limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
      • Detailed - Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
      • Comprehensive - General multi-system examination or complete examination of a single organ system
    • Medical decision making (MDM) - Refers to the complexity of establishing a diagnosis and/or determining a management option. There are four levels of MDM, dependent upon the number of diagnoses, the amount of data analyzed, and the risk of complications.
      • Straightforward
      • Low complexity
      • Moderate complexity
      • High complexity

    1995 Guidelines Versus 1997 Guidelines

    There are two sets of E/M guidelines: 1995 and 1997. The main difference between the 1995 and 1997 guidelines is the examination component. The 1995 guidelines allow more latitude for a detailed exam, by merely stating that two to seven body area or organ systems** may be addressed and documented. To meet a detailed exam using the 1997 guidelines, a physician must document upwards of 12 “bullets” that may or may not be pertinent to the CC at each encounter. Physicians should use one version of the documentation guidelines for an encounter, not a combination of the two.

    **Verify with your local Medicare Administrative Contractor and other payers to determine the amount and complexity of the exam components required.

    2019 Changes

    Effective January 1, 2019, Medicare allowed physicians to document, review, and verify any history entered into medical record by ancillary staff or the beneficiary in lieu of re-entering that information. For established patients only, history and examination already contained in the medical record does not need to be re-entered. Rather, the physician may document what has changed and pertinent items that have not changed since the last visit.