Evaluation and Management Codes

Selecting the correct code for Evaluation and Management services (E&M) and documenting the service level in the medical record are critical to getting paid for services provided and avoiding being audited for incorrect coding. There are five levels of care which relate to the degree of complexity of the visit as documented in the medical record. Physicians who bill a lot of E&M Levels 4 and 5 (high complexity) are most susceptible to audit by Medicare or private health insurers.

The following provides a basic outline of E&M reporting and documentation. For more detailed information, visit CMS' Medicare Learning Network.

Definitions: New Patient, Established Patient, Consult

A new patient is defined as a patient who is self-referred and has not been seen by the physician (or if the physician is in a group/clinic, the group/clinic) in the past three years.

  • CPT® codes 99201-99205 are used to bill established patient visits. Each level is assigned a relative value unit (RVU).

An established patient is a patient who has been seen by the physician/group within the past three years.

  • CPT® codes 99211-99215 are used to bill established patient visits. Each level is assigned an RVU.

A consult is for patient (known or unknown to the physician/group), for whom the physician is asked to:

  • Evaluate and give an opinion about a problem. Documentation of the request for consult from the treating physician must be in the medical record. If request is verbal, it must be recorded in the medical record.
  • The consulting physician sends the visit report to the treating physician.
  • CPT® codes 99241-99245 are used to bill for consults. Each level is assigned a RVU. Consults are assigned higher RVUs than new patient or established patient visits.

Four Components of an E&M Encounter

The physician or staff must document the following four elements, though they may include all four in the descriptions of history of present illness.

  • Chief Complaint (CC)
  • History of Present Illness (HPI)
  • Review of Systems (ROS)
  • Past Medical, Social and Family History (PFSH)
  • Note: ROS and PFSH can be reported by referring to previous exam (e.g.,“no change”) but the data and location of the previous note must be recorded.

This is probably the most important factor in determining level of care. Physicians' must document two of the following three elements:

  • Diagnosis and Management Options
  • Evaluation of Data
  • Risk (of Disease/Testing/Management Decision)

  • Physical Exam
  • Time

Determining Level of Care

The level of care (1-5) will be determined by what occurs during each component of the encounter and appropriate documentation of that. The levels all relate to the level of complexity.

  • Review of Systems: Level determined by number of systems examined directly related to problem presented (higher number, more complex).
  • Physical Exam: Levels range from problem-focused (limited, less complex) to comprehensive (more complex).
  • Decision Making/Risk: Levels range from minimal risk (i.e. self limited problem like a cold) to high risk (i.e. one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment).

CMS offers a Medicare Learning Network with free educational materials for healthcare professions on CMS program, policies and initiatives at cms.org.

Remember: Everything must be documented in the medical record.

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