1. Choosing the Proper Levels
Of
Evaluation & Management
Services
Presented by:
David Klein, CPC, CHC

2. Telling the Story
It’s not Just Documentation that tells the Story…
Everything we do in Practice Tells a Story, for example:
 Cervical Sprain/Strain indicates whiplash injury
 -59 modifier indicates separate site/organ system was
treated
 Our fee schedule reflects how we value our skills
 Level 1 Established Patient Exam indicates a problem
that will likely self resolve

3. Introduction
 Evaluation and Management – E/M codes
 Office or Other Outpatient Services 99201 – 99215
 E/M codes are the most scrutinized codes by third party
payers when it comes to levels of service provided and
utilization guidelines.
 One of the most common mistakes when billing E/M
codes are inappropriate coding due to misinterpretation
of descriptions and definitions.
 The key components and how they determine the level
of service.

4. Terminology
 New Patient - A new patient is one who has not received professional
services from a provider or another provider of the same specialty who
belongs to the same group practice within the past 3 years.
 Established Patient - A patient who has received professional services
within the past 3 years from the provider or another provider of the same
specialty who belongs to the same group practice.
 Chief Complaint - A concise statement from the patient describing the
symptom, problem, condition, diagnosis, or other factor that identifies the
reason for the visit.

5.  Concurrent Care - When more than one provider provides services to a
patient on the same day. Payment for concurrent care is determined by
establishing medical necessity for services performed by more than one
provider.
 Counseling - A discussion with the patient and/or family regarding
diagnoses, test results, medication management, care instructions,
prognosis, or other factors related to the patient’s condition.
 History of Present Illness - A chronological description of the
development of the patient’s present illness, or problem from onset to
present. This must be documented by the provider and not ancillary staff.
 Medical Decision Making - The process for describing the outcome of
the visit, through consideration of the nature of the presenting problem,
diagnoses, treatment and/or management options, diagnostic tests and
procedures ordered, complexity of the condition and risk for complications.

6.  Morbidity - The quality or state relative to a disease process.
 Mortality - The number of deaths in a given time or place.
 Nature of Presenting Problem - A disease, condition, illness, injury,
sign, finding or complaint for which the patient is being seen. The five types
are:
 Minimal – Services may not require the presence of a provider, however,
services are rendered under a provider’s supervision.
 Self-Limited or Minor – A problem that typically runs a definite course, is
transient in nature, and not likely to permanently alter health status.
 Low Severity – A problem in which the risk of morbidity without treatment is
considered to be low; there is minimal risk of mortality without treatment; and full
recovery is expected.
 Moderate Severity – A problem for which the risk of morbidity without
treatment is moderate; there is moderate risk of mortality without treatment or
there is some uncertainty of the prognosis or potential for functional impairment.
 High Severity – A type of problem in which the risk of morbidity and/or
mortality without treatment is high to extreme. There exists a high probability of
severe or prolonged functional impairment.

7.  Past History - A review of the patient’s own medical history related to
trauma, illness, previous surgeries and hospitalizations, including
medications, allergies and other pertinent information.
 Social History - A review of events and activities describing the patient’s
lifestyle, eg. marital status, education, employment, sexual history,
substance use or other relevant social factors.
 Review of Systems - An inventory of the body systems acquired through
a series of questions asked to the patient. The review of systems helps
define possible management options.
 Face to Face Time - This includes only the time the provider spends
face to face with the patient obtaining the history, performing the
examination and counseling the patient and/or family.
 Consultations – Services provided by a provider whose opinion or advice
is requested for a specific condition or problem by another provider or an
appropriate source.

8. The Seven Components of E/M
» History *
» Examination *
» Medical Decision Making *
» Counseling
» Coordination of Care
» Nature of Presenting Problem
» Time
* Key Components

9. History
Four Types:
• Problem Focused
• Expanded Problem Focused
• Detailed
• Comprehensive
Components that determine the extent of history obtained:
1. Chief Complaint/History of Present Illness:
• Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Associated
Signs and Symptoms
2. Review of Systems:
• Constitutional, Eyes, Ears/Nose/Throat/Mouth, Cardiovascular, Respiratory,
Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary, Neurological,
Psychiatric, Endocrine, Hematologic/Lymphatic, Allergic/Immunologic
3. Past, Family, Social History:
• Past History, Family History, Social History

10. History
CC/HPI = 8 Elements ROS = 14 Systems PFSH
Brief 1-3 Elements Problem Pertinent Extended 2-9 Systems Complete 10+ Systems Pertinent 1 Area
Extended 4 or More Complete 2/3 or 3/3
After Determining which level of each history component is applicable, choose
the overall level of history:
HPI + ROS + PFSH = Level 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

11. Examination
1995 Guidelines
Four Types:
 Problem Focused – A limited examination of the affected body area
or organ system.
 Expanded Problem Focused – A limited examination of the
affected body area or organ system and other symptomatic or
related organ system(s).
 Detailed – An extended examination of the affected body area(s)
and other symptomatic or related organ system(s).
 Comprehensive – A general multi-system examination or a
complete examination of a single organ system.

12. Medical Decision Making
The complexity of establishing a diagnosis and/or
selecting a management option is measured by the
following 3 elements:
1. The number of possible diagnoses and/or number of
management options that must be considered.
2. The amount and/or complexity of medical records,
diagnostic tests, and/or other information that must be
obtained, reviewed and analyzed.
3. The risk of significant complications, morbidity and/or
mortality, as well as co morbidities associated with the
patient’s presenting problem(s), the diagnostic procedure(s)
and possible management options.

13. Table of Risk
Level of Diagnostic Procedures Management Options
Presenting Problem(s)
Risk Ordered Selected
One self limited or minor problem;  Lab test requiring venipuncture  Rest
eg. cold, insect bite, tinea corporis  Chest x-rays  Gargles
Minimal
 EKG, EEG  Elastic Bandages
 Urinalysis  Superficial Dressings
 Two or more self limited or minor  Physiologic tests not under stress  Over the counter drugs
problems. eg. pulmonary function tests  Minor surgery with no identified risk
 One stable chronic illness, eg. well  Non-cardiovascular imaging studies factors
Low controlled hypertension, NIDD with contrast, eg. barium enema  Physical therapy
 Acute, uncomplicated illness or  Skin biopsy  Occupational therapy
injury eg. simple sprain, cystitis.  Clinical laboratory tests requiring  IV fluids without additives
arterial puncture
 One or more chronic illnesses with  Physiologic test under stress eg.  Minor surgery with identified risk
mild exacerbation, progression, or cardiac stress test fetal contraction factors.
side effects of treatment. stress test.  Elective major surgery with no
 Two or more stable chronic  Diagnostic endoscopies with no identified risk factors.
illnesses. identified risk factors.  Prescription drug management.
Moderate
 Undiagnosed new problem with  Deep needle or incision biopsy.  Therapeutic nuclear medicine.
uncertain prognosis, (lump in breast).  Obtain fluid from body cavity, eg.  Closed treatment of fracture or
 Acute complicated injury, eg. head lumbar puncture, thoracentesis etc. dislocation without manipulation.
injury with brief loss of
consciousness.
 One or more chronic illnesses with  Cardiovascular imaging studies with  Elective major surgery with identified
severe exacerbation, progression, or contrast with identified risk factors. risk factors.
side effects of treatment.  Cardiac electrophysiological tests.  Emergency major surgery.
 Acute or chronic illnesses or injuries  Diagnostic endoscopies with  Parenteral controlled substances.
High that may pose a threat to life or identified risk factors.  drug therapy requiring intensive
bodily function, eg. progressive  Discography. monitoring for toxicity.
severe rheumatoid arthritis, acute MI,
 Decision not to resuscitate or to
etc.
escalate car because of poor prognosis

14. Four Types of Decision Making:
– Straight Forward
– Low Complexity
– Moderate Complexity
– High Complexity
Determine the type of decision making by choosing which levels of risk
qualify for each element of medical decision making. Two out of three
elements must be met or exceeded to qualify for any given level of
decision making.
Number of DX Amount and/or Risk of Complications
Or Management + Complexity of Data + and/or Morbidity or = Type of
Options to be Reviewed Mortality Decision Making
Minimal Minimal/None Minimal Straight Forward
Limited Limited/Low Low Low Complexity
Multiple Moderate Moderate Moderate Complexity
Extensive Extensive High High Complexity

15. Office or other outpatient services
New Patient 99201-99205
For a new patient, all three key components must be met or exceeded to qualify for a
particular level of service. The overall level of service is selected based on the
performance and documentation of history, examination, and medical decision making.
Code 99201 99202 99203 99204 99205
Expanded
Problem
History Problem Detailed Comprehensive Comprehensive
Focused
Focused
Expanded
Problem
Examination Problem Detailed Comprehensive Comprehensive
Focused
Focused
Medical Low Moderate
Straightforward Straightforward High Complexity
Decision Making Complexity Complexity
Typical Time
Spent Face to 10 Minutes 20 Minutes 30 Minutes 45 Minutes 60 Minutes
Face

16. Office or other outpatient services
Established Patient 99211-99215
For an established patient, two of the three key components must be met or exceeded to qualify for a
particular level of service. The overall level of service is selected based on the performance and
documentation of history, examination, and medical decision making.
Code 99211 99212 99213 99214 99215
Expanded
Problem
History Minimal Problem Detailed Comprehensive
Focused
Focused
Expanded
Problem
Examination Minimal Problem Detailed Comprehensive
Focused
Focused
Medical
Moderate High
Decision Minimal Straightforward Low Complexity
Complexity Complexity
Making
Typical Time
Spent Face to 5 Minutes 10 Minutes 15 Minutes 25 Minutes 40 Minutes
Face

17. Office or Other Outpatient Services
99201 – 99215
 Office or other outpatient service E/M codes are reported for
patients presenting to a physician’s office, outpatient hospital or
other type of ambulatory facility.
 When counseling and/or coordination of care dominates more than
50% or the total time spent face to face with the patient, time may
be the controlling factor in determining the level of service. The
documentation must include how much time was spent for the visit
and how much time was spent counseling/coordinating care.
 Code 99211 may not require the presence of a provider. Any
established patient visit encounter in which the provider is directly
involved in the care of the patient should be coded as a 99212 at a
minimum.

18. When Can You Bill for E/M
Services?
In most cases, the following scenarios
warrant an E/M service:
• New Patient Exam
• Re-Examinations
• Exacerbations
• Patient Presents with New Condition
** If CMT also performed then a modifier is necessary – see next slide

19. 25 Modifier
• 25 Modifier - According to the AMA: “Significant,
separately Identifiable Evaluation and Management
Service by the Same Physician on the same day of the
procedure or other service: The physician may need to
indicate that on the day a procedure or service identified
by a CPT code was performed, the patient’s condition
required a significant, separately identifiable E/M service
above and beyond the other service provided… The E/M
service may be prompted by the symptom or condition
for which the procedure and/or service was provided. As
such, different diagnoses are not required for reporting of
the E/M services on the same date.”

20. For More Information:
Contact David Klein
Phone: 888-306-1256
Email: dave@paydc.com
www.paydc.com