Detailed E&M Coding Course
Click on these links to go directly to the topic:
Common E&M categories
Consultations
Levels of service
History
Exam
Medical decision making
Documentation requirements at various levels
Time-based services
Modifier 25
Clinical examples at various E&M levels
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E&M Services Classifications – most common
 Outpatient - clinic visits
 Consult
 New
 Established
 Inpatient – hospital visits
 Initial
 Subsequent
 Consult, initial and follow-up
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Medicare Outpatient E & M
Approximate Allowables
Outpatient Visit Category
CPT
Code
Level
1
Established
New
Consultation
$18.90
$32.00
$44.20
2
$34.00
$57.90
$81.90
3
$47.40
$86.50
$109.00
4
$74.50
$123.20
$155.00
5
$109.40
$155.00
$201.00
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New or Established Patient
 New patient: has not received any
professional evaluation and management
(E&M) services from the physician or
another physician of the same specialty who
belongs to the same group practice within
the past three years
 Established patient: has received an E&M
service from group within three years
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Consultations
 A Consultation is an E&M service provided by a
physician whose opinion and advice is requested
by another physician or appropriate source
 Consultations should be viewed as a three-part
cycle (1) a request is made (2) an evaluation is
undertaken and (3) an opinion is rendered and
sent to the requesting physician.
 The consultant may initiate diagnostic and/or
therapeutic services at the same visit
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Consultations
 A patient who is self-referred or “referred for
management of a condition” is a new or
established patient, not a consult
 If ongoing care of a particular condition is
assumed in advance, service is not a consult
but a new/est. patient visit
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Consult Documentation Requirements
 Written or verbal request must be
documented. As an example: “Mr. Jones is
seen in consultation at the request of Dr.
Smith for evaluation of worsening
cough.”
 Consultant’s opinion must be
communicated by written report to the
requesting physician
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Levels of Service
Defining Levels of Service
History
Physical Examination
Medical Decision Making
Other Considerations
Time
Counseling
Coordination of Care
Nature of Presenting Problem
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History – Three Parts
History of Present Illness
Review of Systems
Past, Family and Social History
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History of the Present Illness (HPI)
Location
Timing
Quality
Context
Severity
Modifying factors
Duration
Associated signs
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and symptoms
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Two Levels of HPI
 Brief = 1-3 elements described
 Extended = 4+ elements described OR
Status of at least 3 chronic or inactive conditions
Duration
Quality
“Mr. Peters has for two weeks felt a sharp pain in
his left shoulder when he raises his arm.”
Location
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Context
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Review of Systems (ROS)
An inventory of body systems obtained through questions
seeking to identify signs and/or symptoms which the
patient has or has had.
 Constitutional symptoms (e.g.
fever, weight loss)
 Eyes
 Ears, Nose, Mouth, Throat
 Cardiovascular
 Respiratory
 Gastrointestinal
 Genitourinary
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 Musculoskeletal
 Integumentary (including
breasts)
 Neurological
 Psychiatric
 Endocrine
 Hematologic/Lymphatic
 Allergic/Immunologic
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Review of Systems (ROS)
Three levels of ROS:
Problem Pertinent (1 system)
Extended (2-9)
Complete (at least 10)
 May be completed by patient, nurse or other staff
 Pertinent positives and negatives must be referred to in the
note
 May use “all other systems negative” or “the balance of
ten systems reviewed is negative” indicating a complete
ROS was done
 If unable to obtain, document why
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Past, Family and Social History (PFSH)
 Past

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Current medications
Prior illnesses/injuries
Dietary status
Operations/hospitalizations
Allergies
 Family
 Health status or cause of death of siblings/parents
 Hereditary/high risk diseases
 Diseases related to the chief complaint, HPI, ROS
 Social
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
Living arrangements
Marital status
Drug or tobacco use
Occupational/educational history
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Two Levels of PFSH

Pertinent: one of the three areas

Complete: document specific item from
all three areas

Complete for established patients:
two of three areas is sufficient
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Four Levels of History
 Problem focused
Brief HPI
 Expanded problem focused
Brief HPI, Pertinent ROS, no PFSH
 Detailed
Extended HPI and ROS, 1 PFSH element
 Comprehensive
Extended HPI, Complete ROS and PFSH
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History Example
2 y/o male c/o vomiting/diarrhea & 2 day
fever. Diarrhea watery for 4 days, temp
102-103. Vomited 2X this a.m.,  appetite.
Started Pedialyte 3 days ago. Drank several
oz Pedialyte this a.m. Ø rhinorrhea, Ø
cough, Ø daycare
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History Example
bchief complaint
b HPI duration
2 y/o male c/o vomiting/diarrhea & 2 day
b HPI quality
fever. Diarrhea watery for 4 days, temp
b HPI severity
102-103. Vomited 2X this a.m.  appetite.
b HPI modifying factors
Started Pedialyte 3 days ago. Drank several
oz Pedialyte this a.m. Ø rhinorrhea, Ø
cough, Ø daycare
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History Example
2 y/o male c/o vomiting/diarrhea & 2 day
fever. Diarrhea watery for 4 days, temp
b ROS GI
102-103. Vomited 2X this a.m.  appetite.
Started Pedialyte 3 days ago. Drank several
oz Pedialyte this a.m.
b ROS EENT
b ROS Resp b PFSH Social
Ø rhinorrhea, Ø cough, Ø daycare
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History Documented in Example
 Chief Complaint
Always required
 HPI, 4 descriptors
Extended
 ROS, 4 systems
Extended
 PFSH, social (1)
Pertinent
Detailed
= Outpatient established E&M visit @ 99214
new patient or consult @ 99203, 99243
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Documenting the Physical Exam

A general multi-system exam or any single organ
system exam may be performed by any provider.

The type and content are selected by the provider
depending upon medical necessity.
 Note specific abnormal & relevant negative findings of
the affected or symptomatic area(s)--“abnormal” is
insufficient.

Describe abnormal or unexpected findings of
asymptomatic areas or systems.

Noting “negative” or “normal” is sufficient to document
normal findings in unaffected areas.
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The Physical Exam Component
The following slides describe two methods
of determining the level of physical exam:
1995 Guidelines and 1997 Guidelines.
Either may be used. There is no need to
satisfy the requirements of both methods.
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Physical Exam Guidelines (1995)
 Problem Focused
 A limited examination of the affected body area or organ system
 Expanded Problem Focused
 A limited examination of the affected body area or organ system
and other symptomatic or related organ system(s)
 Detailed
 An extended examination of the affected body area(s) and other
symptomatic or related organ systems
 Comprehensive
 A general multi-system examination (8 or more of the 12
systems) or complete examination of a single organ system
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General Multi-system Exam (1997)
See next page for the list of multi-system exam elements
referred to below
 Problem Focused

Documentation of 1-5 elements
 Expanded Problem Focused

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At least 6 elements
One or more organ/body system
 Detailed

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

at least 6 organ/body system covered
for each system/area, at least 2 elements noted
OR
At least 12 elements total
2 or more organ/body systems
 Comprehensive



At least nine organ systems/areas covered
For each, all elements should be performed
Document at least 2 elements in each system/area
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General Multi-system Examination
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(1997 Guidelines)
Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7)
weight (May be measured and recorded by ancillary staff)
General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
Inspection of conjunctivae and lids
Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry)
Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)
External inspection of ears and nose (eg, overall appearance, scars, lesions, masses)
Otoscopic examination of external auditory canals and tympanic membranes
Assessment of hearing (eg, whispered voice, finger rub, tuning fork)
Inspection of nasal mucosa, septum and turbinates
Inspection of lips, teeth and gums
Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx
Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)
Examination of thyroid (eg, enlargement, tenderness, mass)
Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)
Percussion of chest (eg, dullness, flatness, hyperresonance)
Palpation of chest (eg, tactile fremitus)
Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
Palpation of heart (eg, location, size, thrills)
Auscultation of heart with notation of abnormal sounds and murmurs
Examination of:
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carotid arteries (eg, pulse amplitude, bruits)
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abdominal aorta (eg, size, bruits)
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femoral arteries (eg, pulse amplitude, bruits)
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pedal pulses (eg, pulse amplitude)
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extremities for edema and/or varicosities
Inspection of breasts (eg, symmetry, nipple discharge)
Palpation of breasts and axillae (eg, masses or lumps, tenderness)
Examination of abdomen with notation of presence of masses or tenderness
Examination of liver and spleen
Examination for presence or absence of hernia
Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
Obtain stool sample for occult blood test when indicated
MALE:
Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass)
Examination of the penis
Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness)
FEMALE:
Pelvic examination (with or without specimen collection for smears and cultures), including
· Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
Examination of urethra (eg, masses, tenderness, scarring)
Examination of bladder (eg, fullness, masses, tenderness)
Cervix (eg, general appearance, lesions, discharge)
Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)
Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
Palpation of lymph nodes in two or more areas:
Neck
Groin
Axillae Other
Examination of gait and station
Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)
Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower
extremity; and 6) left lower extremity. The examination of a
given area includes:
Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
Assessment of range of motion with notation of any pain, crepitation or contracture
Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements
Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)
Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)
Test cranial nerves with notation of any deficits
Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski)
Examination of sensation (eg, by touch, pin, vibration, proprioception)
Description of patient’s judgment and insight
Brief assessment of mental status including:
 orientation to time, place and person
 recent and remote memory
 mood and affect (eg, depression, anxiety, agitation)
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Single Organ System Examination
 Requirements for elements documented similar to 1997
multi-system
 Single organ system exams for the following:
–Eyes
–Ears,
Nose, Mouth, and Throat
–Cardiovascular
–Respiratory
–Genitourinary
–Musculoskeletal
–Skin
–Neurological
–Psychiatric
–Hematologic/Lymphatic/Immunologic
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Medical Decision Making (MDM)
Based on any two of the following:
 Number of Diagnostic and/or Management
Options
 Amount and Complexity of Data
 Risk
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Medical Decision Making Elements
 Diagnostic and/or management options
(max = 4 “points”)
 Self-limited, minor (1 ea)
 Established problem stable, improved (1 ea)
 Established problem worsening (2 ea)
 New problem, no add’l workup planned (3 ea)
 New problem, add’l workup planned (4 ea)
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Medical Decision Making Elements
 Amount & complexity of data (max = 4 points)
 Review/order of clinical lab, radiologic study, other non-invasive
diagnostic study (1 ea type)
 Discussion of diag study w/interpreting phys. (1)
 Independent review of diagnostic study (2)
 Decision to obtain old records or get data from source other than
patient. (1)
 Review/summary old med records or gathering data from source
other than patient (2)
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Medical Decision Making Elements
 Risk

Presenting problem

Diagnostic procedures

Management options
Choose the highest level of associated risk
expressed in any one of these three categories
on the table on the next page.
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Table of Risk
Risk Level
Presenting Problem(s)
Diagnostic Procedure(s) Ordered
Management Options Selected
•One self-limited or minor problem, eg, cold,
insect bite, tinea corporis
•Laboratory tests requiring venipuncture
•Chest x-rays
•EKG/EEG
•Urinalysis
•Ultrasound, eg, echocardiography
•KOH prep
•Rest
•Gargles
•Elastic bandages
•Superficial dressings
•Two or more self-limited or minor problems
•One stable chronic illness, eg, well controlled
hypertension, non-insulin dependent diabetes,
cataract, BPH
•Acute uncomplicated illness or injury, eg,
cystitis, allergic rhinitis, simple sprain
•Physiologic tests not under stress, eg, pulmonary
function tests
•Non-cardiovascular imaging studies with contrast,
eg, barium enema
•Superficial needle biopsies
•Clinical laboratory tests requiring arterial puncture
•Skin biopsies
•Over-the-counter drugs
•Minor surgery with no identified risk
factors
•Physical therapy
•Occupational therapy
•IV fluids without additives
•One or more chronic illnesses with mild
exacerbation, progression, or side effects of
treatment
•Two or more stable chronic illnesses
•Undiagnosed new problem with uncertain
prognosis, eg, lump in breast
•Acute illness with systemic symptoms, eg,
pyelonephritis, pneumonitis, colitis
•Acute complicated injury, eg, head injury with
brief loss of consciousness
•Diagnostic endoscopies with no identified risk
factors
•Deep needle or incisional biopsy
•Cardiovascular imaging studies with contrast and
no identified risk factors, eg, arteriogram, cardiac
catheterization
•Obtain fluid from body cavity, eg lumbar
puncture, thoracentesis, culdocentesis
•Minor surgery with identified risk factors
•Elective major surgery (open,
percutaneous or endoscopic) with no
identified risk factors
•Prescription drug management
•Therapeutic nuclear medicine
•IV fluids with additives
•Closed treatment of fracture or dislocation
without manipulation
•One or more chronic illnesses with severe
exacerbation, progression, or side effects of
treatment
•Acute or chronic illnesses or injuries that pose
a threat to life or bodily function, eg, multiple
trauma, acute MI, pulmonary embolus, severe
respiratory distress, progressive severe
rheumatoid arthritis, psychiatric illness with
potential threat to self or others, peritonitis,
acute renal failure
•An abrupt change in neurologic status, eg,
seizure, TIA, weakness, sensory loss
•Cardiovascular imaging studies with contrast with
identified risk factors
•Cardiac electrophysiological tests
•Diagnostic Endoscopies with identified risk factors
•Discography
•Elective major surgery (open,
percutaneous or endoscopic) with
identified risk factors
•Emergency major surgery (open,
percutaneous or endoscopic)
•Parenteral controlled substances
•Drug therapy requiring intensive
monitoring for toxicity
•Decision not to resuscitate or to deescalate care because of poor prognosis
Minimal
Low
Moderate
High
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Level of Medical Decision Making Documented
Four levels:

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
Straightforward
Two of the three areas:
Low complexity
dx options, amount of data,
risk establish the MDM level
Moderate complexity
High complexity
Diag/mgt options
0-1
2
3
4
Amount of data
0-1
2
3
4
Minimal
Low
Moderate
High
Strghtfwd
Low
Moderate
High
Overall risk
Level of MDM
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Note on Medical Decision Making Level
Co-morbidities and underlying diseases, in and of
themselves, are not considered in selecting a
level of E/M services unless their presence
significantly increases the complexity of the
medical decision making.
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New Outpatient Visits/Consults
Level
History
99201, 99241Problem Focused (PF)
Exam
MDM
PF
Straightforward
99202, 99242
Expanded prob
focused (EPF)
EPF
SF
99203, 99243
Detailed
Detailed
Low
99204, 99244
Compr.
Compr.
Moderate
99205, 99245
Compr.
Compr.
High
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Established Outpatient Visits
Level
History
Exam
MDM
99211
N/A
N/A
N/A
99212
PF
PF
SF
99213
EPF
EPF
Low
99214
Detailed
Detailed
Moderate
99215
Compr.
Compr.
High
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Initial Hospital/Observation
Level
History
Exam
MDM
99221,
99218
Detailed
Detailed
SF/Low
99222,
99219
Compr.
Compr.
Moderate
99223,
99220
Compr.
Compr.
High
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Subsequent Hospital and Follow-up Consults
Level
History
Exam
MDM
99231,
99261
PF
PF
SF/LOW
99232,
99262
EPF
EPF
Moderate
99233,
99263
Detailed
Detailed
High
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Documenting Time-based Coding
 If time spent counseling and/or coordinating
care is more than 50% of encounter, use time
 May count TP face-to-face time only for OP,
coordination, time on floor for IP
 Document amount of time counseling and total
time spent on encounter and describe
counseling, coordination activities
 Document only minimal history, exam OR
medical decision making
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Time as the Controlling Factor
Established patient
New patient,
Consultation
99211
Approximate time
Nurse visit, 5 supv
99212
99201, 99241
10 / 10 / 15
99213
99202, 99242
15 / 20 / 30
99214
99203, 99243
25 / 30 / 40
99215
99204, 99244
40 / 45 / 60
99205, 99245
60 / 80
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Examples of Time-based Codes
 Critical care
 Other E&M visits where >50% counseling
 Individual psychotherapy codes (non E&M)
 Prolonged services
TP presence or concurrent observation for entirety of time-based
services
Resident note may support level and type service, add’l TP
summary note to document involvement
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Modifier 25
 Append a modifier 25 to an E&M code if a significant, separately
identifiable E&M service is performed by the same physician on
the same day of a procedure or other service.
 The patient’s condition must require E&M services above and
beyond what would normally be performed in the provision of the
procedure.
 The necessity for the E&M service may be prompted by the same
diagnosis as the procedure.
 A new patient E&M service is considered separate from the
same day surgery or procedure—no 25 modifier needed.
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Modifier 25
 For an established patient, if the E&M service resulted in the
initial decision to perform a minor procedure (0-10 days global
period) on the same day and medical necessity indicates
an E&M service beyond what is considered normal
protocol for the procedure, the 25 modifier is appropriate.
 To determine the correct level of E&M service to submit,
identify services unrelated to the procedure and use as
E&M elements.
 Clearly mark the encounter form to indicate that a 25
modifier should be attached to the E&M.
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Clinical Examples—Primary Care
New patient 99204
 Initial office visit for a 17-yr-old female with depression
 Initial office visit for initial evaluation of a 63-yr-old male with
chest pain on exertion
 Initial office visit for evaluation of 70-yr-old patient with recent
onset of episodic confusion.
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Clinical Examples—Primary Care
Established patient 99213
 Office visit for a 62-yr-old female, established patient, for
follow-up for stable cirrhosis of the liver.
 Office visit for a 60-yr-old, established patient, with chronic
essential hypertension on multiple drug regimen, for blood
pressure check.
 Office visit for a 50-yr-old female, established patient, with
insulin-dependent diabetes mellitus and stable coronary
artery disease, for monitoring.
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Clinical Examples—Primary Care
Established Patient 99214
 Office visit for a 28-yr-old male, established patient, with
regional enteritis, diarrhea, and low-grade fever.
 Office visit for a 28-yr-old female, established patient, with
right lower quadrant abdominal pain, fever, and anorexia.
 Office visit with 50-yr-old female, established patient, diabetic,
blood sugar controlled by diet; complains of frequency of
urination and weight loss, blood sugar of 320 and negative
ketones of dipstick.
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Clinical Examples—Primary Care
Established Patient 99215
 Office visit with 30-yr-old, est. patient, for 3- month history of
fatigue, weight loss, intermittent fever, and presenting with
diffuse adenopathy and splenomegaly.
 Office visit for evaluation of recent onset syncopal attacks in a
70-yr-old woman, est. patient.
 Office visit for a 70-yr-old female, est. patient, with diabetes
mellitus and hypertension, presenting with a two-month history
of increasing confusion, agitation and short-term memory loss.
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Where To Get Help
 www.med.unc.edu/compliance/
 UNC P&A Professional Charges 962-8391
 School of Medicine Compliance Office 843-8638
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