Evaluation & Management (E&M) Coding: Essentials for Accuracy and Compliance
Correctly selecting and documenting Evaluation and Management (E&M) service levels is essential for proper reimbursement - and for avoiding audits. E&M services are billed according to the complexity of the visit, with five levels of care ranging from minimal to high complexity. Physicians who frequently bill Level 4 or 5 (high complexity) visits are more likely to be audited by Medicare or private insurers.
The following provides a basic overview of E&M coding. For more detailed guidance, visit the CMS Medicare Learning Network.
Patient Categories & Associated CPT® Codes
New Patient: Not seen by the physician or group in the past three years.
CPT® codes: 99201–99205
Established Patient: Seen by the physician or group within the past three years.
CPT® codes: 99211–99215
Consult: Referred by another provider for evaluation and opinion. Requires documentation of the request and a report sent back to the referring physician.
CPT® codes: 99241–99245 (typically assigned higher RVUs)
Key Components of an E&M Visit
History
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Review of Systems (ROS)
- Past, Family, and Social History (PFSH)
Note: ROS and PFSH may reference prior notes if properly cited.
Medical Decision Making (MDM)
Must include two of the following:
- Diagnosis and management options considered
- Data reviewed or ordered
- Risk of complications, morbidity, or mortality
Physical Exam
- Varies in complexity from problem-focused to comprehensive
Time (if applicable)
- Total time spent may be used to determine the level if appropriately documented
Determining the Level of Care (1–5)
The level billed depends on the complexity of services provided and the supporting documentation in the medical record.
- ROS: Number of systems reviewed
- Exam: Scope of physical exam performed
- Risk: Based on presenting problems, diagnostic procedures, and management options
Reminder: Thorough, accurate documentation is required for every E&M service billed.
Visit the CMS Medicare Learning Network for free, up-to-date educational materials on coding, policies, and more.