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.
E/M 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 a visit's 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.
Changes Coming in 2021
In response to advocacy from the AAFP and other specialty societies, the AMA revised the methodology to document and select CPT levels for office visit E/M services. These fundamental changes (www.ama-assn.org)are intended to reduce administrative burden and increase the amount of time physicians spend caring for patients.
Beginning January 1, 2021, physicians will have the option to select the level of visit using either time or medical decision making (MDM). In addition, the definition of time will expand to include all time on the date of service, and the MDM criteria will be updated. The patient history and physical exam elements will be eliminated as components of E/M level code selection.
The Centers for Medicare & Medicaid Services (CMS) will use the updated methodology, meaning the 1995 and 1997 guidelines will no longer apply. CMS will also increase the relative values for the office visit E/M codes. The AAFP will continue to advocate for uniform adoption of the changes across all payers.
The AAFP has championed and supports the move to reduce administrative burden in primary care. Through the changes don't go into effect until 2021, practices should begin preparing now. The AAFP is developing resources to assist with implementation.
Practices can get started with the following resources:
2021 Office Visit Evaluation and Management Documentation Changes: A Checklist for Solo and Independent Physicians(2 page PDF)
This checklist is designed specifically to help small, solo, and independent practices understand what steps to take throughout the year to ensure readiness for 2021. The AAFP will provide additional resources to help you through the checklist.
2021 Office Visit Evaluation and Management Documentation Changes: A Checklist for Employed Physicians(2 page PDF)
This checklist offers steps an employed physician can take to better understand their employer’s training plan and ensure that their employment contracts are updated appropriately.
2021 Office Visit Evaluation and Management Documentation Changes: Questions to Ask Your Vendors(4 page PDF)
The updated documentation guidelines will impact 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.
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 Systems (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)
E/M Tips and Tricks
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.)
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 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.
What's New in 2019?
Effective January 1, 2019 Medicare allows physicians to document review and verification of any history entered into the 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 need not be re-entered. Rather, the physician may document what has changed and pertinent items that have not changed since the last visit.
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.