This document discusses evaluation and management coding for psychiatric services. It covers the 1995 and 1997 E/M guidelines, including differences in documentation requirements. Key aspects of history, examination, and medical decision making are outlined. Proper documentation of the chief complaint, history of present illness, review of systems, and past/family/social histories is important. Examination requirements vary based on level of service. Medical decision making considers diagnosis, data review complexity, and patient risk. Special documentation is needed for counseling or coordination of care. Overall, the document provides guidance on selecting and documenting evaluation and management codes for outpatient psychiatric care.

1. Evaluation and
Management
Coding
Psychiatry Related Coding
Outpatient Care
This Photo by Unknown Author is licensed under CC BY-NC-ND
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

2. Psychiatric
Services
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

3. Evaluation and Management
Types of Services
 Consultation
 Hospital Admission
 Office Visits
 Well Visits
 Emergency Visits
 Nursing Facility Visits
 Etc.
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

4. What do payers want and why?
The site of service
The medical necessity and
appropriateness of the
diagnostic and/or
therapeutic services
provided
Services provided have been
accurately reported
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

5. Evaluation and
Management
Guidelines
 *Required and published by CMS
 *Two Versions—1995 and 1997
 *Provider selects a version for consistent use
with all E/M services
 *The 1997 Guidelines calls for a greater detail
or a “bullet point” approach
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

6. Difference between 1995 and 1997
Guidelines
 1995 Guidelines provide a great level of detail regarding the history and
examination but leave the medical decision making vague.
 Many providers felt the medical necessity should be the driving force behind
the code selection. This lead to upcoding evaluation and management
services.
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

7. 1997 E/M
Guidelines
The 1997
version works
well in a
template format
or EHR format
for documenting
medical records
The 1997
version also
produced a
single system
specialty
examination
guidelines
There are 11
types of exams
The most
problematic
area for
auditors are the
histories and
examiantions
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

8. Documentation of Documentation 1997
Guidelines
 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 or organ system
 Detailed—Extended examination of the affected body
area or organ system and any other symptomatic or
related body area or organ system
 Comprehensive—A general multi system examination
or complete examination of a single organ system and
other symptomatic or related body area or organ
system
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

9. Behavioral Evaluation and Management Coding
 The 1997 Documentation Guidelines are often beneficial. It is important that
the psychiatric examination is taken into consideration.
 The psychiatric template should include the following:
➢ General appearance (development, nutrition, body habitus, grooming
➢ Vital Signs
➢ Examination of gait and station
➢ Muscle strength and tone
➢ Orientation to time, place, and person
➢ Description of speech
➢ Recent and remote memory
➢ Description of patient’s judgement and insight
➢ Any repeating phrases and thoughts
➢ Description of abnormal psychotic thoughts
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

10. New
Patient
Coding
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

11. Evaluation and Management
 ESTABLISHED
PATIENT
CODING
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

12. Documentation
for Patient
Encounters
A reason for the encounter and relevant
history, physical examination findings, and
prior diagnostic tests results.
Assessment, clinical impression, or
diagnosis
Plan for care
Date and legible identity of provider
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

13. Patient Status
New patient—One who has not
received professional service
from the physician or another
physician of the exact same
specialty and subspecialty who
belongs to the same group
practice, within the past 3
years.
Established patient—One who
has received professional
service from the physician or
another physician of the exact
same specialty and
subspecialty who belongs to
the same group practice,
within the past 3 years.
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

14. Evaluation &
Management
Factors
Three Factors of Evaluation and
Management Code
1. Place of Service
2. Type of Service
3. Patient Status
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

15. Nature of
Presenting
Problem
 Level of Complexity of the patient’s problem or
condition upon presentation to the physician
 Minimal
 Self limiting or minor
 Low severity
 Moderate severity
 High severity
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

16. Evaluation and Management Services
History of Present
Illness
Review of
Systems
PFSH Type of History
Brief N/A N/A Problem Focused
Brief Problem Pertinent N/A Expanded Problem
Focused
Extended Extended Pertinent Detailed
Extended Complete Complete Comprehensive
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

17. Evaluation
and
Management
Coding
Chief Complaint-Concise statement describing the symptom,
problem, condition, or other factors that is the reason for the
visit.
Family History-Review of the patient’s family history that
would contribute to the patient’s risk.
History of Present Illness- Chronological development of the
patient’s illness
Nature of presenting problem-Minimal, Self-limiting or minor,
low severity, moderate severity, high severity.
Past History, Family History, and Social History
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

18. History Four Elements—Subjective
CC: Chief
Complaint
1
HPI: History
of Present
Illness
2
ROS: Review
of Systems
3
PFSH: Past,
Family, Social
History
4
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

19. Key Components of History
Elements Problem
Focused
Expanded
Problem
Focused
Detailed Comprehensiv
e
HPI
History of
Present Illness
Brief (1-3
elements)
Brief
(1-3 elements)
Extended
(4 or more
elements)
Extended
(4 or more
elements)
ROS
Review of
Systems
None Problem
Specific
Extended Complete
PFSH
Past Medical,
Family and
Social History
None None Pertinent Complete
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

20. Examination
Problem Focused-Limited examination
usually one body part of one complaint
Expanded Problem Focused-Limited
examination of the affected body part
(usually 2-4 body parts/elements)
Detailed-Extended examination of the
affected body part or related organ
systems (usually 5-7 body parts/elements)
Comprehensive-General multisystem
examination or a complete single organ
system (8 or more body parts/elements)
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

21. Medical Decision Making (MDM) Complexity
Diagnosis or
management
option
Amount and
complexity of
data to review
Patient Risk
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

22. Medical Decision Making
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

23. Contributing
Factors
 Counseling
 Coordination of Care
 Nature of presenting
problem
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

24. Counseling
 Documentation must
support that greater
than 50% of the face
to face visit was
spent in counseling or
coordination of care.
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC

25. Management
Options
Stated or implied decisions regarding plan or
evaluation
Improving, well controlled, resolving
Worsening, inadequately controlled, failing to
change
Ordering, planning, or performing additional
assessments
Referrals, consultations documented
Created by Laura Murdock, CPPM, CMPE, SHRM-SCP, WCCP, SIP, CPC