E&M Services are those services provided by physicians and non-physician practitioners to evaluate patients and manage their care. The code is chosen based on where the service is performed, the extent of history taken, the extent of the examination and the level of medical decision making.

Selecting the Level of E&M Service

1 . Determine the place of service (examples):

• Physician Office
• Outpatient Hospital
• Inpatient Hospital
• Outpatient Ambulatory Surgical Center
• Emergency Room-Hospital
• Home (patient’s)
• Hospice
• Skilled Nursing Facility
• Residential Substance Abuse Treatment Facility
• Comprehensive Rehabilitation Facility

2. Using the CPT book, identify the category for the service rendered and review the guidelines or instructions unique to the category or subcategory of service selected.

3. Determine the complexity of medical decision making; the extent of history obtained; and the extent of the exam performed.

4. Based on the category/subcategory selected for the E&M service, select the correct code.

The following are the categories/subcategories of E&M Service:

(found in front of the CPT Manual)

Office or Other Outpatient Services

New Patient 99201-99205

Established Patient 99211-99215

Hospital Observation Discharge Services 99217

Hospital Observation Services 99218-99220

Hospital Observation or Inpatient Care

Services (Including Admission and Discharge Services) 99234-99236

Hospital Inpatient Services

Initial Hospital Care 99221-99223

Subsequent Hospital Care 99231-99233

Hospital Discharge Services 99238-99239

Consultations

Office Consultations 99241-99245

Initial Inpatient Consultations 99251-99255

Follow-up Inpatient Consultations 99261-99263

Confirmatory Consultations 99271-99275

Emergency Department Services 99281-99288

Pediatric Patient Transport 99289-99290

Critical Care Services

Adult (over 24 months of age) 99291-99292

Pediatric 99293-99294

Neonatal 99295-99296

Intensive Care (Low Birth Weight) 99298-99299

Nursing Facility Services

Comprehensive Nursing Facility Assessments 99301-99303

Subsequent Nursing Facility Care 99311-99313

Nursing Facility Discharge Services 99315-99316

Domiciliary, Rest Home or Custodial Care Services

New Patient 99321-99323

Established Patient 99331-99333

Home Services

New Patient 99341-99345

Established Patient 99347-99350

Prolonged Services

With Direct Patient Contact 99354-99357

Without Direct Patient Contact 99358-99359

Standby Services 99360

Case Management Services

Team Conferences 99361-99362

Telephone Calls 99371-99373

Care Plan Oversight Services 99374-99380

Preventive Medicine Services

New Patient 99381-99387

Established Patient 99391-99397

Individual Counseling 99401-99404

Group Counseling 99411-99412

Other 99420-99429

Newborn Care 99431-99440

Special E/M Services 99450-99456

Other E/M Services 99499

Patient Status:

New patient: One who has not received professional services from the physician or another physician of the same specialty in the same group within the past 3 years.

Established patient: One who has received professional services from the physician or another physician of the same specialty in the same group within the past 3 years.

Outpatient: One who has not been formally admitted to a health care facility.

Inpatient: One who has been formally admitted to a health care facility.

Defining the Level of Service:

• Key components (history, examination, and medical decision-making complexity).
• Contributing factors (counseling, coordination of care, nature of presenting problem, and time)

Key Components

Four Elements of a History:

• Chief Complaint (CC): Reason for the encounter in the patient’s words
• History of Present Illness (HPI): Location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms.
• Review of Systems (ROS):
  • Constitutional symptoms Genitourinary
  • Eyes Musculoskeletal
  • Ears, Nose, Mouth, Throat Integumentary
  • Cardiovascular Neurologic
  • Respiratory Psychiatric
  • Gastrointestinal Endocrine
  • Hematologic/Lymphatic Allergic/Immunologic
• Past, Family, and/or Social History (PFSH):

Past illnesses, operations, injuries, and treatments; family medical history for heredity and risk; social activities, both past and current.

Examination Levels:

• Problem Focused:Limited to affected body area or organ system
• Expanded problem focused: Limited to affected body area or organ system and other related organ system(s)
• Detailed: Extended exam of affected area(s) and other symptomatic or related organ systems
• Comprehensive: Complete single organ system specialty exam or general multi-system exam

Medical Decision-Making Elements:

• Straightforward: Minimal diagnosis or treatment options; minimum or no amount/complexity of data; minimal risk if left untreated.
• Low Complexity: Limited diagnosis or treatment options; limited amount/complexity of data; low risk if left untreated.
• Moderate Complexity: Multiple diagnoses or treatment options; moderate amount/complexity of data; moderate risk if left untreated.
• High Complexity: Extensive diagnoses or treatment options; extensive amount/complexity of data; high risk if left untreated.

Contributing Factors

Counseling: Consists of discussion of diagnostic results, impressions, and recommended diagnostic studies; prognosis, risks and benefits of treatment; instructions for treatment, and patient and family education.

Coordination of Care: Consists of coordinating the care of a patient with other health care providers or agencies.

Nature of Presenting Problem: Consists of the patient’s chief complaint.

Time: Represents a simple estimate of the possible duration of a service.

Selection of Appropriate Level of E/M Service:

A. For the following categories, all of thekeycomponents must meet or exceed the stated requirements to qualify for a particular level of E/M service: new patient, office; hospital observation services; initial hospital care; office consultations; initial inpatient consultations; confirmatory consultations; emergency department services; comprehensive nursing facility assessments; domiciliary care, new patient; and home, new patient.

B. For established patients, only 2 out of the 3 key components must be met.

Consultations:

A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. In order to bill for a consultation:

1. A request must be made by the primary physician or insurance company for the consultation.

2. The physician must render a medically necessary service to the patient which includes the elements necessary to substantiate the consultation: history, exam, medical decision making. (follow-up inpatient consultations require only 2 out of the 3 components).

2. The physician providing the consultation must report the findings of the consultation by letter to the requesting physician.

Categories of Consultations:

• Office or Other Outpatient Consultations – new or established patient.
• Constitutes consultations provided in the physician’s office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care, or emergency department
• Follow-up visits in the consultant’s office or other outpatient facility that are initiated by the physician consultant are reported using office visit codes for established patients.
• Initial Inpatient Consultations – new or established patient.
• Constitutes consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting. Only one initial consultation should be reported by a consultant per admission.

• Follow-up Inpatient Consultations – established patient.
• Constitutes visits to complete the initial consultation or subsequent consultative visits requested by the attending physician; includes monitoring progress, recommending management modifications or advising on a new plan of care in response to changes in the patient’s status.
• Confirmatory Consultations – new or established patient.
• Constitute evaluation and management services provided to patients when the consulting physician is aware of the confirmatory nature of the opinion sought (eg. When a second/third opinion is requested or required on the necessity or appropriateness of a previously recommended medical treatment or surgical procedure.

Preventive Care Services:

• Managed care plans take a “wellness approach” to medicine, and assert that a well patient costs fewer benefit dollars than an acute, chronic or catastrophically ill patient who has not been treated or diagnosed previously. This environment promotes frequent check-ups and testing for early detection and treatment of health problems. A preventive care code is used when a patient who is asymptomatic indicates the intent to obtain a routine examination and/or screening.
• An age and gender specific history and exam are performed for preventive care services.
• If, during the course of the preventive medicine visit, an abnormality or preexisting problem is addressed, physicians may receive payment for that part of the visit; however, the problem should be significant enough to warrant additional work that meets the requirements of at least a problem oriented E&M visit. In this case, that part of the visit may be billed by using the appropriate office/outpatient service code with the modifier 25 (significant, separately identifiable E&M service by the same physician, same day) along with the preventive medicine code.
• Codes in the preventive care subsection of the CPT book do not include immunizations and other ancillary services involving laboratory, radiology or other procedures. These procedures are reported separately.

Establishing Medical Necessity

Per HCFA, a “service that is reasonable and necessary for the diagnosis and treatment of illness and injury, or to improve the functioning of a malformed body member.”

• The need for an item or service must be clearly documented in the patient’s medical record.
• The item or service must be appropriate for the symptom and diagnosis orof thecondition, illness, disease, or injury.
• The item or service must be the most appropriate supply, procedure, or level of service that can be safely provided to the patient.
• The item or service must be in accordance with current standards of good medical practice.

1. E&M Coding and Documentation Guide, Ingenix, Inc. 6 th ed., 2003, JH Kurac, “The Building Blocks of Evaluation and Management Coding”, pp 7-29.

2. Center for Medicare and Medicaid Services: www.cms.hhs.gov/medlearn/qrfs.asp#edu.

3. Current Procedural Terminology, Professional Edition, American Medical Association, 2004.