1. Building an E/M Code
The Basics of Evaluation &
Management Services
Department of Revenue Integrity

2. Charting History
 Medical records tell a story about a patient’s care
and treatment. Whether it’s a fifteen minute
consultation or a weeklong hospital stay, all of the
time a patient is seen by someone in healthcare, is
tracked.
 Medical record documentation is required to record
pertinent facts, findings and observations about an
individual’s health history, including past and
present illnesses, examinations, tests, treatments
and outcomes.
 It’s imperative that as coders, we read through the
documentation and accurately pick up certain
pieces so that we can determine a level of visit.
 By laying brick upon brick, buildings are built. We
do the same with our E/M codes by adding together
elements from documentation to support a level of
visit.

3. E/M Factors to consider
Type of service (TOS)
Visit, consult, observation?
Place of service (POS)
Emergency room, office,
inpatient hospital,
outpatient hospital, etc.
Patient Status
New vs. Established

4. Patient status
 A coder should be able to determine from the medical record
whether or not the patient is NEW or ESTABLISHED.
 CPT defines a new patient as “one who HAS NOT received any
professional services from the physician or another physician of
the same specialty who belongs to the same group practice,
within the past three years.”
 An established patient is “one has HAS received professional
services from the physician or another physician of the same
specialty who belongs to the same group practice, within the past
three years.”
 You’ll also notice in CPT that new patients require 3/3 key
components, whereas established patients require 2/3. This
determination is based on work performed and prior knowledge of
the patient and their needs.

5. New patient visits

6. Established patient visits

7. Places of service
 There are many different places of
service for patients to be seen:
Offices, hospitals (inpatient and
outpatient), observation, emergency
departments, nursing facilities,
domicilaries, and patient’s homes.
 By locating the place of service, it
determines a certain range of codes and
rules out a group that cannot be reported.

8. Components that make up E/M services
 Key Components:
History
Examination
Medical Decision Making
 Contributory Components:
Counseling
Coordination of Care
Nature of presenting
problem (illness)
Time

9. Key Components
 History
 Examination
 Medical Decision Making
Office or other outpatient services
Hospital observation services
Hospital inpatient services
Consultations
Emergency Department services,
Nursing facility services,
Domiciliary care services
Home Care Services

10. Key Component: History
 The history element is made up of four
types of history:
 Chief Complaint (CC)
 History of Present Illness (HPI)
 Review of Systems (ROS)
 Past, Family & Social History (PFSH)

11. HISTORY: Chief Complaint (CC)
 Defined as “a concise statement
describing the symptom, problem,
condition, diagnosis, or other factor that is
the reason for the encounter, usually
stated in the patient’s own words”.
 A chief complaint must be present in all
charts to count toward an E/M level of
service.

12. HISTORY: Chief Complaint (cont.)
Examples:
 “Patient presents for follow-up of
fracture care…”
 “38-year old female is complaining of
build-up of ear wax…”
 “17-year old male was in high-speed MVA
and is complaining of headache, neck
pain and shoulder pain.”

13. HISTORY: History of Present Illness (HPI)
 Defined as a “chronological description of
patient’s present condition from time of onset to
present”.
 May not always include a timeline of events
 May not be stated in the patient’s own words if
unable to speak (i.e. CVA, trauma, etc.)
 Clues can be given by family or other medical
personnel present at scene if trauma
 Includes eight description terms that may be met
when calculating the HPI

14. HISTORY: HPI Descriptors
 Location
  Severity
  Duration
  Associated Signs/Symptoms
  Quality
  Context
  Timing
  Modifying Factors

15. HISTORY: HPI
 Location
 WHERE on the body the
symptom is occurring
 i.e. chest pain
 i.e sore throat
 i.e. knee swelling
Some questions physicians
will ask are:
 Is the pain diffuse or
localized?
 Unilateral or bilateral?
 Fixed or migratory?
 If documented, give one
point for location.

16. HISTORY: HPI
 Severity
 A rank of the
symptom/pain on a scale
from 1-10.
 May also be described as
severe, slightly, “worst I’ve
ever had”, mild, moderate,
increasing, decreasing,
progressive, well.
 If documented, give one
point for severity.

17. HISTORY: HPI
 Duration
 Describes how long the
symptom/pain has been
present or how long it
lasts when the patient has
it
 i.e. 20 minutes
 i.e. 3 years ago
 i.e. since last Friday
 i.e. approximately two
months ago
 i.e. yesterday
 If documented, give one
point for duration.

18. HISTORY: HPI
 Associated Signs/Symptoms
 Describes the
symptom/pain and other
things that happen when
this symptom/pain occurs.
 i.e. chest pain leads to
shortness of breath
 Headache leads to visual
disturbances
 If documented, give one
point for associated
signs/symptoms.

19. HISTORY: HPI
 Quality
 Describes the
character or type of
the symptom/ pain
 i.e. sharp
 i.e. dull
 i.e. burning
 If documented, give
one point point for
quality.

20. HISTORY: HPI
 Context
 Describes HOW it
happened; situation
associated with the
pain/symptom
 i.e. exercise, dairy
products, in an MVA,
running down the
steps, sitting in a
chair
 If documented, give
one point for context.

21. HISTORY: HPI
 Timing
 Describes WHEN the
pain/symptom occurs
or establishes the
onset for each
symptom (why and
when) and a rough
chronology of the
event(s) surrounding
 If documented, give
one point for timing.

22. HISTORY: HPI
 Modifying Factors
 Were medications
taken to counter the
effects of pain? Did
the patient eat or lay
down? What was
done in an attempt to
resolve the issue?
 If documented, give
one point for
modifying factors.

23. HISTORY: HPI Types
 There are two
types of HPI and
they factor into
the E/M level.
Notice once you
have four
elements of HPI,
you’re now in the
detailed range.
 Be careful when
counting these.
Brief 1-3
elements
Extended 4+
elements
(’95)
OR 3
chronic
conditions
(’97)

24. Example of History: HPI
Patient complains of stabbing, intermittent
chest pain which began eight hours ago
while watching television. He rated the pain
as 8/10 in severity and is worse with exertion. It is
also associated with SOB and nausea.

25. Example Answer
Patient complains of stabbing, intermittent
chest pain which began eight hours ago
while watching television. He rated the pain
as 8/10 in severity and is worse with exertion. It
is also associated with SOB and nausea.
Timing
Quality
Location Duration
Context
Severity
Modifying
factor
Associated S/S

26. HISTORY: Review of Systems (ROS)
 An inventory of body systems obtained
through a series of questions, seeking to
identify signs and/or symptoms that the
patient may be experiencing or may have
experienced.
 There are fourteen body systems/areas
that are covered in this element.

27. HISTORY: ROS
Constitutional (fever,
weight loss, etc.)
Musculoskeletal
Eyes Integumentary (skin
and/or breast)
Ears, Nose, Throat Neurological
Cardiovascular Psychiatric
Respiratory Endocrine
Gastrointestinal Hematological/lymphatic
Genitourinary Allergic/ immunological

28. HISTORY: ROS Types
 There are three types
of ROS.
 Problem focused is
not relevant in ROS
because to have 1
ROS element, you
already are at the
expanded problem
focused history.
Problem
pertinent
Focuses on
sole problem
Extended Inquires
about the
system
directly
related to the
problem (2-9
systems)
Complete Inquires
about all
systems
(10+)

29. Example of History: ROS
 Patient admits to lower back pain, loss of
balance and dizziness. He denies nausea,
vomiting, fever or chills. Also he denies
abdominal pain, urinary frequency, and painful
urination. He further denies chest pain, SOB and
headaches. Does admit to fatigue and anxiety.

30. Example Answer
 Patient admits to lower back pain, loss of
balance and dizziness. He denies nausea,
vomiting, fever or chills. Also he denies
abdominal pain, urinary frequency, and painful
urination. He further denies chest pain, SOB and
headaches. Does admit to fatigue and anxiety.
Musculoskeletal
Neuro
Gastro
Constitutional
Genitourinary
Cardio
Respiratory
Hemat Psych

31. Checklist: ROS
GEN c/o occ malaise and weight gain
EYES No blurred vision
CVS No CP, DOE, PND, orthopnea, syncope, palpitations
RESP No cough, wheezing, hemoptysis, SOB
GI No N/V/D/C, melena, heartburn, pain
GU No dysuria, urgency, hesitancy, nocturia, incontinence
SKIN No ulcers, itching, dryness, rash
MUSC No joint pain, gait disturbance, cramps
NEURO No confusion, memory loss, seizures, LOC, occ headache
OTHERS Remaining systems are negative

32. HISTORY: PFSH
 PFSH is an abbreviation for past, family
and social history which make up the third
part of the history element.
 These three types of history paint a
clearer picture for the physician to help
narrow down a specific injury, alert the
physician to a need for testing in a certain
area, or provide background for medical
decision making.

33. HISTORY: PFSH
 Past history (patient’s past
experiences with
illnesses, operations,
injuries and treatments)
 Family history (a review of
medical events in the
patient’s family, including
diseases which may be
hereditary or place a
patient at risk
 Social history (age
appropriate review of past
and current activities)
Social
Family
Past

34. HISTORY: PFSH Types
 There are two types
of PFSH.
 Problem focused and
expanded problem
focused are not
relevant as they don’t
require any of the
PFSH types for a
certain level to be
met.
Pertinent At least 1
item from
any of the
three areas
(must be
directly
related to
HPI)
Complete 2-3 areas

35. Example of History: PFSH
 HPI: Coronary artery disease.
 PFSH: Patient returns to office for follow
up of CABG in 1992. Recent cardiac
catheterization demonstrates 50%
occlusion of vein graft to obtuse marginal
artery.

36. Example Answer
 HPI: Coronary artery disease.
 PFSH: Patient returns to office for follow
up of CABG in 1992. Recent cardiac
catheterization demonstrates 50%
occlusion of vein graft to obtuse marginal
artery.
 DIRECT RELATION TO HPI
One
element

37. PFSH Requirements NEW Pts:
 At least one specific
item from EACH of
the history areas
(past, family AND
social history) must
be documented for
the following
categories of E/M
services to obtain a
comprehensive
PFSH.
3/3 Office or other outpatient
svcs, new
Hospital observation
services
Hospital inpatient
services, initial
Comprehensive
NF assessments
Domiciliary care,
new pt
Home care, new pt

38. PFSH Requirements EST Pts:
 At least one specific
item from TWO of the
three history areas
(past and family,
family and social, or
social and past) must
be documented for a
complete PFSH.
2/3 Office or other
outpatient services,
established
Emergency
Department
Domiciliary care, est.
Subsequent NF care
Home care, est.

39. History Recap
 Documentation requirements
Level of
Hx
Problem
Focused
Expanded
Problem
Focused
Detailed Comprehensive
HPI 1-3 1-3 4+ 4+
ROS 0 1 2-9 10
PFSH 0 0 1 2/3

40. Important E/M rules to remember:
 Levels do not crosswalk.
 Some codes are based on time.
 The chief complaint, ROS and PFSH may
be listed as separate elements of history,
or they may be included in the description
of the HPI. Pay attention to only pull what
is necessary as long as the
documentation is provided.

41. Important E/M rules (cont.)
 An ROS and/or a PFSH obtained during
an earlier encounter doesn’t need to be
re-recorded if there is evidence that a
physician reviewed and updated the
previous information.
 This does NOT mean that
copying/pasting is allowed by any
physician.

42. Important E/M rules (cont.)
 If the physician is unable to obtain history,
from the patient or other source, the
reason why should be listed.

43. Key Component: Examination
 An examination is a thorough evaluation
from head to toe of a patient, who is
presenting with an illness/injury.
 There are two kinds of acceptable
examinations approved by CMS. They
are the 1995 guidelines and the 1997
guidelines. They are made up of body
areas and organ systems.

44. Examination
BODY AREAS
Head (including face)
Neck
Chest (breasts/axillae)
Abdomen
Genitalia, groin,
buttocks
Back, spine
Each extremity

45. Examination
ORGAN SYSTEMS
Constitutional (e.g., vital signs,
general appearance)
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/Lymphatic/
Immunologic

46. 1995 Guidelines:
 The levels of E/M services are based on four types of
examination that are defined as follows:
 https://www.cms.gov/MLNProducts/Downloads/1995dg.pdf
Problem focused Limited exam- affected body area or
organ system
Expanded problem
focused
Limited exam- affected body area or organ
system & other symptomatic or related
organ system(s).
Detailed Extended exam- affected body area(s) and other
symptomatic or related organ system(s).
Comprehensive Multi-system exam or complete exam of a single
organ system

47. 1997 Guidelines:
 https://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf
• Problem Focused Examination-should include performance and documentation of one to five
elements identified by a bullet (•) in one or more organ system(s) or body area(s).
• Expanded Problem Focused Examination-should include performance and documentation of
at least six elements identified by a bullet (•) in one or more organ system(s) or body
area(s).
• Detailed Examination--should include at least six organ systems or body areas. For each
system/area selected, performance and documentation of at least two elements identified
by a bullet (•) is expected. Alternatively, a
detailed examination may include performance and documentation of at least twelve
elements identified by a bullet (•) in two or more organ systems or body areas.
• Comprehensive Examination--should include at least nine organ systems orbody areas. For
each system/area selected, all elements of the examination identified by a bullet (•) should
be performed, unless specific directions limit the content of the examination. For each
area/system, documentation of at least two elements identified by a bullet is expected.

48. Differences in Exams:
Problem focused
one body area or organ system
Problem focused
1-5 bulleted elements
Expanded problem-focused
2+ body areas and/or organ systems
Expanded problem focused
6-11 bulleted elements
Detailed
5+ body areas and/or organ systems
Detailed
12-17 bulleted elements for 2+
systems
Comprehensive
8+ body areas and/or organ systems
Comprehensive
18+ bulleted elements for 9+ systems
1995 guidelines 1997 guidelines

49. Key Component: MDM
 The last piece that helps determine an E/M is the
Medical Decision Making. This piece is a little bit
more complex, but relevant to determining a
level.
Medical Decision Making Types
Straight
forward
Low Moderate High

50. Complexity of MDM
 Two of the three elements must be met or exceeded to
qualify for a given type of MDM, or drop to the lowest.
Number of
diagnoses or
management
options
Amount and/or
complexity of
data to be
reviewed
Risk of
complications
and/or morbidity
or mortality
Type of decision
making
Minimal Minimal or
none
Minimal Straightforward
Limited Limited Low Low
Multiple Moderate Moderate Moderate
Extensive Extensive High High

51. Number of Dx or Mgmt Options
 The number of possible diagnoses and/or
the number of management options that
must be considered is based on the
number and types of problems addressed
during the encounter, the complexity of
establishing a diagnosis and the
management decisions made by the
physician.

52. Number of Dx or Mgmt Options
 Generally, decision-making with respect to a
diagnosed problem is easier than that for an
identified but undiagnosed problem.
 The number and type of diagnostic tests
employed may be an indicator of the number of
possible diagnoses.
 Problems which are improving or resolving are
less complex than those which are worsening or
failing to change as expected.
 The need to seek advice from others is another
indicator of the complexity.

53. Amt and/or complexity of data
 The amount and complexity of data to be
reviewed is based on the types of
diagnostic testing ordered or reviewed. A
decision to obtain and review old medical
records and/or obtain history from
sources other than the patient increases
the amount and complexity.

54. Amt and/or complexity of data
 Discussion of contradictory or unexpected
test results with the physician who
performed or interpreted the test is an
indication of the complexity of data being
reviewed. On occasion, the physician
who ordered a test may personally review
the image, tracing or specimen to
supplement information from the
physician who prepared the test report or
interpretation.

55. Risk of Significant Complications, Morbidity and/or Mortality
 These are based on the risks associated with the
presenting problem(s), the diagnostic
procedure(s), and the possible management
options.
 The table of risk breaks down different
categories.
Levels of risk are determined by the risk of the:
 Presenting problem(s)
 Diagnostic procedure(s) ordered
 Management options selected

56. How do I build an E/M level?
 There are so many complexities and facets I
have to address when extracting data from a
chart. Where do I even begin!?

57. Calculating an E/M Level
 When calculating the
history portion, all
three elements in a
row must be met
(HPI, ROS and
PFSH). You must
have 3/3 for a given
category in the table,
or you must drop to
the lowest level.
Level
1-3
HPI
0 ROS 0
PFSH
PF
1-3
HPI
1 ROS 0
PFSH
SPF
4+ HPI 2-9
ROS
1
PFSH
D
4+ HPI 10+
ROS
2/3
PFSH
C

58. Calculating an E/M Level
 When
calculating
the exam
portion,
choose the
exam that
matches
how many
levels were
met.
LEVEL
1 Area/System PF
2-7 Systems EPF
2-7 Systems or 3+ each
system
D
8+ Systems C

59. Calculating an E/M Level
Number of
diagnoses or
management
options
Amount
and/or
complexity of
data to be
reviewed
Risk of
complications
and/or
morbidity or
mortality
Type of decision
making
Minimal Minimal or
none
Minimal Straightforward
Limited Limited Low Low
Multiple Moderate Moderate Moderate
Extensive Extensive High High

60. Number of Dx or Mgmt Options
Self-limited or minor (stable, improved, or worsened)
Max 2 points
1 point
Established problem (to examining MD); stable or improved 1 point
Established problem (to examining MD); worsening 2 points
New problem (to examining MD); no additional workup
planned
Max 3 points
3 points
New problem (to examining MD); additional workup (eg,
admit/transfer)
4 points

61. Amt and/or Complexity of Data Reviewed
Lab ordered and/or reviewed 1 point
X-ray ordered and/or reviewed 1 point
Medicine section (90701-99199) ordered and/or reviewed 1 point
Discussion of test results w/ performing physician 1 point
Decision to obtain old records and/or obtain hx from someone
other than the pt
1 point
Review and summary of old records and/or obtaining history
from someone other than patient and/or discussion with another
health provider
2 points
Independent visualization of image, tracing or specimen (not
simply review of report)
2 points

62. Table of Risk
 See attached table of risk (separate)
 Choose the highest risk out of each of the
categories.
 Because your MDM needs 2/3 elements to be
satisfied, you can choose the highest risk and be
sure to tally the points so that your level can be
justified. However, due to the other two grids,
the level may be lowered.

63. E & M Clinical Examples

64. E/M Coding Example
HISTORY -- DETAILED
HPI:
Location (bronchial asthma)
Timing (one day per week)
Context (exercize induced)
Modifying factors (treated with Albuterol Inhaler)
ROS:
Respiratory (snoring & sleep apnea)
Psych (depression)
GI (GERD symptoms)
PFSH:
Past (history of aspirin intolerance)
Social (no environmental changes)
EXAM – EXP. PROB. FOCUSED
Constitutional (general condition/VS)
Eyes (conjunctivae)
ENT (TM/nasal mucosa)
Respiratory (lungs)
Cardio (CVS)
MDM -- MODERATE
4 Diagnoses
Prescription Drug Mgmt
BILLED AS: 99213
SUPPORTS: 99214
REQUIRED FOR NEXT LEVEL:
“All other systems reviewed & negative”
3 other body systems in Exam

65. HISTORY – EXP. PROB. FOCUSED
HPI:
Location (arms, legs & neck)
Associated signs & symptoms (not puritic nor
painful)
ROS:
Constitutional (no fevers)
All/Immuno (allergies reviewed and updated)
PFSH:
Past (immunization history, unremarkable)
EXAM – EXP. PROB. FOCUSED
Constitutional (VS)
Eyes (conjunctivae)
ENT (TM/no erythema)
Respiratory (without rhonchi, wheezes)
Cardio (RRR, no murmurs)
GI (soft, NT/ND)
Skin (large vesicular-bullous lesions)
MDM -- LOW
1 new problem – no additional work-up
Obtaining history from someone other than pt
OTC drugs
BILLED AS: 99213
SUPPORTS: 99213
REQUIRED FOR NEXT LEVEL:
2 elements HPI
8 ROS or “all others reviewed…”
1 additional body system in exam

66. Clinical example:
1.
An established patient is seen in the clinic for
allergic rhinitis. A problem focused history, EPF
exam and a low level of MDM were performed.
What E/M code would be reported for the visit?
a. 99212
b. 99213
c. 99214
d. 99215

67. Clinical example answer:
1.
b. 99213
Established patient requires 2/3 key
components.

68. Clinical example:
2.
A patient is admitted to the hospital for a lung
transplant. The admitting physician performs a
comprehensive history, a comprehensive exam,
and a high level of MDM. What CPT code
should be reported?
a. 99221
b. 99222
c. 99223
d. 99234

69. Clinical example answer:
2.
c. 99223
Initial hospital care codes require 3/3 key
components to be met.

70. Clinical example:
3.
A new patient is seen in the pediatric office for ear pain. The
patient has had pain for four days and it keeps her awake
at night. She has had a slight fever (99 degrees). She
has not been swimming or actively in water for the past
couple of months. She denies any cough, nasal
congestion, or stuffiness, or loss of weight. The provider
does a limited exam on the ears, nose, throat and neck.
The patient is determined to have otitis media. Amoxicillin
is prescribed. What E/M code would be reported for this
visit?
a. 99201
b. 99202
c. 99203
d. 99204

71. Clinical example answer:
3.
b. 99202
For a new patient visit, all three key
components must be met. This visit has
an EPF HPI, EPF exam and moderate
MDM for prescription drug management.

72. Clinical example:
4.
A 45-year old patient is seeing the neurologist, Dr. Williams,
at the request of his family physician to evaluate
complaints of weakness, numbness, and pain in his left
hand and arm. The pain started last year after rocks fell
on him while mining. He still has significant, sharp,
burning wrist pain and reports the problems are continuing
to get worse. He is limited in his job as a machinist for a
mining company due to the pain and numbness. He has
no swelling in his hand, no neck pain, or radiating pain.
His past medical history is negative for significant diseases.
He has had carpal tunnel surgery. He has a family history
of hypertension, heart disease, and stroke. He is married
with children and smokes one pack of cigarettes/day.

73. Clinical example (cont.)
A detailed exam is performed of the mental status, cranial nerves,
motor nerves, DTRs, sensory nerves, and head and neck.
After performing an EMG and NCS, Dr. Williams determined the
patient has left ulnar neuropathy, at the cubital tunnel region, as
well as ongoing carpal tunnel syndrome. Repeat carpal tunnel
surgery is recommended, along with a possible cubital tunnel
surgical procedure. If the patient does not have surgery, he risks
permanent nerve damage. A report is sent back to the physician
requesting the consult. What E/M consultation code would be
reported for this visit?
a. 99242
b. 99243
c. 99244
d. 99245

74. Clinical example answer:
4.
b. 99243
A consultation requires all three key
components be met to support the level of
visit.
There is a detailed history, detailed exam
and a moderate MDM for the elective
major surgery.

75. Contributory Components
 Counseling
 Coordination of Care
 Nature of Presenting Problems, and
 Time

76. Contributory Component: Counseling
 May be included during the visit of a patient and
reflect conversations with the patient and/or
family regarding risk reduction, treatment
options, benefits and risks associated with
differing treatment options and other education
given to the patient/family.
 Often occurs when there is a complicated
illness/injury or when there is a newly diagnosed
patient with an acute or chronic illness posing a
threat to life.

77. Counseling example:
 “I had an extremely extensive 60+ minute
examination and series of discussions with
the patient and her family members. Over
half of the time was spent on counseling
them. At great length, with the patient
and her daughter, and later with her son-
in-law who arrived secondarily, and later
again with her husband, who arrived at the
end of my visit, I discussed how diabetic
injury, especially with neuropathy, she
would be at risk, over time, of valvular
dysfunction in the leg veins. I discussed
the anatomy and physiology of orthostatic
hypotension, and how this can be very
pronounced, especially in long-term
diabetics…”

78. Contributory component: Coordination of care
 Usually with other providers or agencies
 Without a patient encounter on that day
 Reported with case management codes
 Example:
Physician spends 20 minutes assessing a patient with
recurrent ear infections.
Spends additional 20 minutes counseling parents with
strategies to decrease the incidence of ear infections,
treatment options and allaying parent anxiety.
99213 E/M selected on the basis of time criteria (more than
50% of face-to-face encounter dominated by counseling).

79. Contributory component: Nature of
presenting problem(s)
 Reason for visit: sign, symptom, illness,
or disease being treated
 Minimal- may not require presence of
physician, services are provided under
physician’s supervision.
Examples: removal of sutures, supervised
drug screen, patient needs release for
school/work.

80. Contributory component: Nature (cont.)
 Self-limited or minor-
Does not permanently alter health status
and with management and compliance
has an outcome of “good”.
Typically heal well on their own without
physician supervision.
Examples: poison ivy, poison oak
exposure, sore throat, resolved tonsillitis

81. Contributory Component: Nature (cont.)
 Low-
Risk of morbidity/mortality without
treatment is low and full recovery with no
functional impairment is expected.
Examples: management of a
hypertensive patient on medication,
established patient for follow up of
osteoporosis, painful bunion.

82. Contributory Component: Nature (cont.)
 Moderate-
Risk of morbidity/mortality without
treatment is moderate, uncertain
prognosis or increased probability of
prolonged functional impairment.
Examples: diabetic w/ complications, s/p
MI patient who is not doing well on
medication, patient with new onset of
RLQ abdominal pain

83. Contributory Component: Nature (cont.)
 High-
Risk of morbidity/mortality without
treatment is highly probable; uncertain
prognosis or high probability of severe
prolonged functional impairment.
Examples: s/p transplant patient
developing new symptoms or cancer
patient with signs of paralysis

84. Contributory Component: Time
 “When counseling and/or coordination of care
dominates (more than 50%) the physician/patient
and/or family encounter…” (CPT guidelines)
 May include face-to-face time in the office or
other outpatient setting, or floor/unit time in the
hospital or nursing facility, and includes time
spent with parties who have assumed
responsibility for the care of the patient or
decision making whether or not they are family
members.

85. Contributory Component: Time (cont.)
 Time the physician spends taking the
patient’s history or performing an
examination does not count as counseling
time.
 He/She must look at the entire patient
encounter and determine if they spent the
majority of time in counseling and/or
coordination of care or if they should bill
using an E/M.

86. Contributory Component: Time (cont.)
 Counseling and coordination of care could include
discussion with the patient (or his or her family) about one
or more of the following, according to CPT guidelines:
 Diagnostic results
 Impressions and/or recommended diagnostic studies
 Prognosis
 Risks and benefits of treatment options
 Instructions for treatment and/or follow-up
 Importance of compliance with chosen treatment options
 Risk-factor reduction
 Patient/family education

87. References:
 E/M University, http://emuniversity.com
 Current Procedural Terminology (2011). (2011). Chicago : American
Medical Association
 Buck, C. (2010) Step-by-Step Medical Coding. Retrieved May 28, 2011.
www.educode.com/vaees (private access)
 2011 Medical Coding Training (2011). Salt Lake City: American Medical
Association
 Department of Health and Human Services. Evaluation and Management
Services Guide. , 2010. Web.
28 Jun 2011.
<https://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide-
ICN006764.pdf>.
 Pierce, B. (2008) Advanced Coding Education Guide for Evaluation and
Management Auditing.
Rockville: DecisionHealth.

88. THANK YOU!
 I appreciate your time in joining us today to
refresh your understanding of the E/M process.
 So many of you have been doing this for years
and I understand and appreciate the talent you
have in determining levels.
 Let’s continue to stay on task and use the proper
rules for coding these visits, so that we can
maintain accuracy and compliance within the
health care system.
-Grace Bower, CPC
Outpatient Coding/Billing Liaison

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