Coding for Evaluation and Management Services
The evaluation and management (E/M) patient visit is the core of most family physician practices. Family physicians and other qualified providers can maximize payment and reduce stress associated with audits by understanding how to properly document and code E/M patient visits.
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, among other things, are determined by the visit complexity and documentation requirements.
Get a high-level overview of the E/M components. Detailed information, including documentation requirements, is available in the AAFP’s Coding Reference Cards: 1995 Basic Evaluation and Management Codes.
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
- 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. Systems include:
- Constitutional (e.g., vital signs, general appearance)
- Ears, nose, throat
- Integumentary (skin/breast)
- 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 (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)
- 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 in which selection is dependent upon the number of diagnoses, amount of data analyzed, and risk of complications.
- Low complexity
- Moderate complexity
- High complexity
1995 vs 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 2-7 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.
Already purchased the AAFP Coding Reference Cards: 1995 Basic Evaluation and Management Codes? Have the desk reference card handy while watching or listening to this short video.