This document provides comprehensive coding guidelines for evaluation and management (E/M) services in internal medicine, focusing primarily on history, examination, and medical decision-making factors that influence coding levels. A crucial aspect discussed is the necessity of documenting a clear chief complaint to establish medical necessity for billing. Accurate coding is vital for ensuring appropriate reimbursement, compliance with regulations, and effective communication in patient care.

1. Coding Guidelines For Evaluation And Management Services In
Internal Medicine: Part 1

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Coding Guidelines For Evaluation And Management Services In Internal
Medicine: Part 1
Evaluation and management (E/M) services play a crucial role in the practice of internists, and accurate coding for these
visits is essential for the financial well-being of medical practice. However, determining the appropriate level of billing
for an E/M code can be challenging for many physicians. In this comprehensive guide, we will outline the coding
guidelines for evaluation and management services in internal medicine, focusing on the documentation standards and
the elements that drive the selection of the appropriate code level.
As there are several factors affecting accurate E/M code selection, we divided these guidelines into two parts. In this
first part we will review three basic factors namely, History, Examination, and Medical Decision Making (MDM) while
other factors like billing based upon time, billing for services provided by staff, and consultations will be discussed in the
next part.
The Role of Chief Complaint
Every E/M visit should start with a chief complaint, which represents the reason why the patient needs to be seen.
Documenting the chief complaint is crucial as it establishes the medical necessity, which is a fundamental requirement
for both Medicare and private insurance billing. The chief complaint can be a simple explanation, such as “cough,” “1-
year recheck of diabetes,” or “nausea since Tuesday.” It is important to avoid generic chief complaints like “annual
checkups” or “feeling sick.” Furthermore, stating “no complaints” or “no symptoms” should be avoided, as such claims
could lead to serious problems if audited. Therefore, documenting a chief complaint is an essential step before selecting
a code for proper billing.

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Coding Guidelines For Evaluation And Management Services In Internal
Medicine: Part 1
Therefore, documenting a chief complaint is an essential step before selecting a code for proper billing.
1. History
History encompasses all subjective information gathered from the patient, obtained through an interview or
questionnaire. There are three key elements of the history to consider when selecting a coding level: History of Present
Illness (HPI), Review of Systems (ROS), and Past, Family, and Social History (PFSH).
• History of Present Illness (HPI): The HPI includes specific elements that aid in determining the coding level. It is
crucial for physicians to ask for pertinent information relevant to the patient’s condition and avoid unnecessary
inquiries aimed at reaching a higher coding level.
• Review of Systems (ROS): The ROS involves asking the patient about their health in each body area or organ system.
The ROS is often overlooked in documentation, leading to codes that do not meet high standards for history. There
are 14 different body areas and organ systems considered for ROS. While it may not be necessary to ask about all
areas in certain cases (e.g., a bruised knee in a healthy individual), a lower-level code should be used. Many
physicians find it helpful to use a form completed by the patient to capture the review of systems, allowing the
patient to document their information.
• Past, Family, and Social History (PFSH): In addition to the patient’s current health, it may be appropriate to inquire
about their past medical history, family history, and social history. These elements are considered part of the overall
history.

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Coding Guidelines For Evaluation And Management Services In Internal
Medicine: Part 1
To reach the highest level of code for a new patient, a physician must gather information about the patient’s past
medical, family, and social history. Past medical history involves documenting previous medical ailments or surgeries,
while family history includes a list of medical ailments affecting the patient’s family members, including causes of death.
Social history covers broad categories like the patient’s history with drugs, alcohol, employment, and education.
2. Examination
The examination component of an E/M visit is relatively straightforward. The level of examination is determined by the
number of body areas or organ systems examined. The more areas or systems examined, the more complex the exam is
considered to be. Physicians may count organ systems for higher-level codes. It is important to align the extent of the
exam with the patient’s presenting problem. A patient with a relatively simple problem usually does not require a
comprehensive exam. Performing an extensive exam solely to raise the coding level is inappropriate and may be
considered fraudulent. Similarly, inadequate documentation when more comprehensive documentation is necessary
does not serve the patient’s best interests.
3. Medical Decision Making
Medical decision-making is the most complex and subjective element of an E/M code. It involves making judgments
about the severity of diagnoses or treatment options, the complexity of reviewed data, and the risk of complications or
morbidity/mortality. Three considerations contribute to the scoring of the medical decision-making section:

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Coding Guidelines For Evaluation And Management Services In Internal
Medicine: Part 1
• Number and Severity of Diagnoses or Treatment Options: The complexity of decision-making increases with the
difficulty of deciding the patient’s treatment. While a complex rubric exists, a basic principle is that the more
challenging the decision-making process, the higher the score.
• Amount and Complexity of Data Reviewed: This includes all data reviewed that is not part of the history or
examination, such as lab studies, x-rays, or reviewing old records. Ordering a study is considered reviewing the study
itself, and data need not be reviewed before dismissing the patient. The more data reviewed by the physician, the
higher the score in this section.
• Risk of Complications and/or Morbidity or Mortality: This section consolidates elements from other areas and
evaluates the risk associated with the presenting problem, diagnostic procedures ordered, and management options
selected. Each element is categorized as minimal, low, moderate, or high risk. While guidelines provide some
guidance, interpretation plays a significant role in assessing risk, often leading to different scoring by different
individuals.
To summarize, accurate coding for evaluation and management services in internal medicine is crucial for both patient
care and the financial health of a practice. Understanding the elements that determine the coding level, including the
documentation requirements for history, examination, and medical decision-making, is essential. Physicians must
document the chief complaint, gather relevant information for the patient’s history, perform an appropriate examination
based on the patient’s presenting problem, and assess the medical decision-making complexity.

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Email us at: richard.smith@medisysdata.com
Coding Guidelines For Evaluation And Management Services In Internal
Medicine: Part 1
By adhering to coding guidelines for evaluation and management services, internists can ensure accurate billing,
appropriate reimbursement, and compliance with regulatory requirements. Proper documentation and coding not only
support reimbursement but also contribute to effective communication among healthcare providers and continuity of
patient care. In the second part of this article, we discussed alternative billing methods for E/M services such as billing
based on time, incident-to-billing for staff services, and billing for consultations.
Medisys Data Solutions (MDS)
Medisys Data Solutions (MDS) is a trusted medical billing company specializing in providing efficient internal medicine
billing services. With our expertise and knowledge of the intricacies of medical coding and billing, MDS ensures accurate
and timely reimbursement for internal medicine practices. Our team of skilled professionals understands the unique
challenges faced by internists in documenting and coding evaluation and management services. By leveraging our
expertise in medical billing, MDS can help internists optimize revenue, improve practice efficiency, and maintain
compliance with coding guidelines and regulations.
To gain a comprehensive understanding of internal medicine billing services, we encourage you to get in touch with us.
You can reach us via email at info@medisysdata.com or by calling our dedicated phone line at 888-720-8884. Feel free
to contact us, and our knowledgeable team will be more than happy to assist you.

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