2. E/M services,
learning objectives:
Identify an E/M service.
Identify and describe 3 key components of E/M coding.
Identify differences in history, examination, and medical decision making
processes.
Identify steps to selecting an E/M level of service.
3. What is an evaluation and management code?
Evaluation and management or
“E/M” codes are the codes used when
reporting an encounter with a
medical professional.
E/M codes are used for encounters in
any form and place of service.
E/M codes are located in the first
section of your CPT books.
The guidelines are located before the
codes and after the contents for that
section. Also you will find others
throughout the section above and
below various codes.
4. Evaluation and management
(E/M) services include:
Office visits
Hospital visits
Consultations
Emergency dept.
Critical care
Nursing facilities and rest homes
Home services
•Prolonged services
•Case management
•Preventative medicine
•Non face to face services(telephone
consultations)
5. Commonly used terms
New/established patient - established patient has been to that doctor within the past 3 years.
Chief complaint - concise statement describing the symptom, problem, condition, or other factor that is the
reason for the encounter.
Counseling - discussion with the patient and/or patient’s family regarding test results, prognosis, treatment,
compliance, and education.
Presenting problem - disease, condition, illness, injury, complaint or other reason for the encounter.
System review - inventory of body systems affected. Obtained by a series of questions about the signs or
symptoms.
Time - in this section refers to the time spent bedside or face-to face with the doctor.
6. E/M visits consist of 3 key components
A history & examination
Problem focused
Expanded problem focused
Detailed
Comprehensive
Medical decision making of various complexities.
Also included, but not key: counseling, nature of presenting problem, and time
spent bedside.
7. History
History type C.C. R.O.S. Illness
History
Past, Social,
and Family
Problem
focused
required N/A brief N/A
Expanded
problem
focused
required Problem
pertinent
brief N/A
Detailed required extended extended pertinent
Comprehensive required complete extended complete
Chart courtesy of U.S. department of health and human services
8. Examination
Type of Exam Description
Problem focused Limited examination of the affected body
area or organ system
Expanded problem focused The above + other symptomatic or related
organ system
detailed An extended examination of the affected
body area, system or other related areas or
systems
comprehensive A general multisystem examination or
complete examination of a single organ
system. Note: extent is based on risk factor
and patient age.
Chart courtesy of U.S. department of health and human services
9. Extent differences
Extent of history obtained
Extent of examination
performed
Problem focused
Chief complaint(CC);brief
history of present problem or
illness
Expanded problem focused
All of above + problem
pertinent system review
Detailed
All of above + system review
extended to add’l systems;
pertinent history related to
present illness
Comprehensive
All of above + complete history
Problem focused
Limited exam of affected area
Expanded problem focused
Limited exam of affected area,
organ system, and other
symptomatic or related area
Detailed
Extended exam of the problem
area.
Comprehensive
general multisystem
examination or complete exam
of a single organ system.
10. Medical decision making
The chart below depicts the elements for each level of
medical decision making. Note that to qualify for a given
type of medical decision making, two of the three
elements must either be met or exceeded.
TYPE OF
DECISION
MAKING
NUMBER OF
DIAGNOSES OR
MANAGEMENT
OPTIONS
AMOUNT AND/
OR
COMPLEXITY OF
DATA TO BE
REVIEWED
RISK OF
SIGNIFICANT
COMPLICATION
S, MORBIDITY,
AND/OR
MORTALITY
Straightforward Minimal Minimal or none Minimal
Low Complexity Limited Limited Low
Moderate
Complexity
Multiple Moderate Moderate
High Complexity Extensive Extensive High
Chart courtesy of U.S. department of health and human services
11. Instructions for selecting a level of E/M service
Review the reporting instructions for the selected category or sub category.
Review the level of E/M service descriptors and examples in selected category
or subcategory
Determine extent of history obtained
Determine extent of examination performed
Determine complexity of medical decision making
12. Instructions for selecting a level of E/M service
cont’d
1. All of the key components must meet or exceed
the stated requirements to qualify for a particular
level of E/M service: home, new patient
office, new patient
initial hospital care
office consultations
hospital observation
emergency dept. services
initial nursing facility care
domiciliary care, new patient
initial inpatient consultations
13. Instructions for selecting a level of E/M service
cont’d
2. Two of the three components meet or exceed
qualifications for
subsequent hospital care
office, established patient
and home, established patient
subsequent nursing facility care
domiciliary care, established patient
3. When counseling or coordination of care dominates the
encounter(more than 50%) then time shall be
considered the key or controlling factor to qualify for the
service level of services.
14. American Association of Professional Coders, 2012, Evaluation and
management training.
Retrieved from:
http://static.aapc.com/3f227f64-019f-488a-b5a2-
e864a522ee71/4a63dfc4-4906-4d83-943f-51fb16115f7e/39fb5570-a301-
4557-9439-0e7a47f45129.pdf
American medical association, 2014, current procedural terminology
U.S. department of health and human services, 2010, Evaluation and
management services guide(ICN006764)
Retrieved from :
http://www.cms.gov/Outreach-and- Education/Medicare-
Learning-Network-
MLN/MLNProducts/downloads/eval_mgmt_serv_guide-
ICN006764.pdf
Editor's Notes
Mention inpatient/outpatient differences
Remind students that risk factors, transfer of care, and coordination of care not discussed here.
