Chapter 7 (p. 193)
Evaluation and Management
Physicians report codes for their services, located in the front
of the manual. Dr sees a pt, generates charges.
 Evaluation of the pt

Decision making process
 How they manage that pt
Format of E/M Codes (p. 194)
1. Unique code begins w/ 99
2. Place or type of service (phys office, out-pt service,
initial/subsequent hospital care)
3. Extent or level of service (detailed history and
detailed examination)
4. Nature of presenting problem (moderate severity)
5. Amount of time typically required to provide a
service.
Eval/Mgmt Document Guidelines (99201-99496)
Developed by AMA and CMS to help clarity code assignment.
Posted on CMS website.
Code Assignment for E/M Services
 What type of Pt? (New/Old)
 New Pt not seen by group in same (sub)specialty
w/in 3 yrs in
 What is the location of the service? (Office,
Observation unit, Consult, LTC, Home Services, etc)
(p. 193-4)
 What level of care?
Concurrent Care
Limit of 1 physician per day in same specialty.
Consultants can submit claims.
Transfer of Care: Explicitly given responsibility for Pt care to
another Pt. Not consulting.
Key Factors to determine appropriate E/M code assignment
(3) and drive code selection of new pt
 History
 Examination
 Medical Decision Making
Contributing Factors (4) (when > 50% time w/Pt or family)
 Counseling
 Coordination of care
 Presenting problem
 Time
Documentation Guidelines (DG) provide requirements and
definitions to help make determinations of levels in each
of the 3 Key Factors/Elements so the coder may assign
the correct E/M code.
Page | 1
History (p. 198)
 Problem-focused: CC + brief HPI or condition
 Expanded problem-focused: CC + brief HPI +
problem pertinent ROS (subjective by Pt)
 Detailed: CC + expanded HPI + problem pertinent
ROS + pertinent PSFH
 Comprehensive: CC + extended HPI + ROS directly
related to problem ID'd in HPI + complete ROS +
complete PSFH
ROS = Review of Systems
PFSH = Past, Family, Social History
As long as Dr has attested and signed off on having reviewed
a system (nurses notes of review) then it can be used in
the coding process. If it is covered in the Pt's intake
forms, if Dr. signed off on it, it can be used. It does not
have to be repeated in dictation.
Chief Complaint (CC) must be on each record somewhere. It
may not say 'chief complaint', but the information must
be presented. Not real helpful in determining level of
visit. It locates a position for data to collect.
See Table 7.3 (at end) to understand determination of History
Type.
Examination (p. 202)
1997 Guidelines (expanded single system exams) used
below. 1995 Guidelines may also be used.
 Problem-focused: Limited to affected body area
(aba) or organ system (os) -- 1-5 elements
 Expanded problem-focused: Exam of aba/os, as well
as symptomatic or related (s/r) os – at least 6
elements
 Detailed:Extended exam of aba(s) and other s/r os –
2 elements in each of 6 areas or 12 elements in 2+
areas/systems
 Comprehensive: A gen’l multisyst exam or complete
exam of a single-organ system and s/r aba/os – All
elements in at least 9 os/aba and documentation of
at least 2 elements in those 9 areas/systems.
 Need at least specific system "Normal" to count a body
system. Can't use "____ system abnormal" without an
explanation.
See Table 7.4 (at end) to understand Examination
Determination
Chapter 7 (p. 193)
Evaluation and Management
Medical Decision Making (p. 205)
Use Figure 7.1/2000 Decision Table (p. 207).
 # of Dx (Number X Points)
 Amt/Complexity of the data
 Risk of complications, morbidity, mortality Table of
Risk on pg. 50 of guidelines
Highest 2 of 3:
 Straightforward: 1 or none (each) Minimal
 Low Complexity: 2 (each) Low
 Moderate Complexity: 3 (each) Moderate
 High Complexity: 4+ (each) Extensive
Counseling and Coordination of Care (p. 206)
Discussion of Pt care w/Pt or Pt’s family. Includes diagnositic
studies, Tx options, instructions.
 Dr. documents total time of visit
 Dr includes specific time spent in
counseling/coordination of care activities
Nature of Presenting Problem (p. 208)
Reason for the encounter, with or without established Dx. 5
types of presenting problems:
 Minimal: Dr not needed to be present for care (BP check)
 Self-limited or Minor: Temporary problem. Condition is
transient. (upper resp. infection)
 Low Severity: Problem with low risk of morbidity and
little or no risk of mortality. Expected full recovery (acne)
 Moderate Severity: With no Tx, Pt’s prognosis may be
uncertain or prolonged functional impairment increased.
 High Severity: With no Tx, risk of morbidity high and
possible severe, prolongued functional impairment.
Page | 2
Time (p. 210)
Face-to-Face Time
Unit/Floor Time
Hospital Observ. Services
In-Pt Hospital Care
Initial In-pt Hospital Consultants
Nursing Facility Care
Instructions for Selection and/or Validation of E/M Service
Levels (p. 211)
1.
2.
3.
4.
5.
ID category and subcategory of service
Review specific notes and instructions for the selected
category and subcategory
Review narrative descriptors and 7 components should
be reviewed for appropriate level of service code
Using definitions under each level of service:
a. determine extent of history obtained
b. determine extent of exam performed
c. determine complexity of medical decision making
(MDM)
Select or verify the appropriate level of E/M Services.
(Tables below)
Chapter 7 (p. 193)
Evaluation and Management
Page | 3
3 Key Elements that Define E/M Services (Tbl 7.1): Use 1997 Guidelines for exams
History
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Examination
Medical Decision Making
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Straightforward
Low Complexity
Moderate Complexity
High Complexity
Determining the Type of History (Tbl 7.3)
Components of a History
History Component
(equal to lowest category documented)
Chief Complaint _________________
*(CC required for all history types)
HPI--History of Present Illness
Problem-Focused
Expanded
ProblemFocused
Brief:
1-3 HPI elements
documented
Detailed
Comprehensive
Brief:
1-3 HPI elements
documented
Extended:
4+ HPI or status of
3+ chronic
conditions
documented
Extended:
4+ HPI or status of
3+ chronic
conditions
documented
None
Problem specific:
1 system
Complete:
>10 systems or
some with all
other negative
None
None
Extended:
2-9 systems
Need specific
system "Normal"
and can't use
system "abnormal"
without
explanation
Pertinent:
At least 1 item
from at least one
history area
__Location
__Severity
__Timing
__Duration
__Quality
__ Context
__ Modifying factors __Assoc. signs/symptoms
ROS--Review of System(s)
__Constitutional
(wt loss, etc)
__Eyes
__GI
__ENT, mouth
__GU
__Cardiovascular __MS
__Respiratory
__Integumentary
__Endocrine
__ Neurologic
__ Psychiatric
__ Hem/Lymph
__Allergy/immun
PFSH (past medical, family, and social history)
__Previous medical (past experience
w/illness, injury, surgery, medical Tx, and so
on)
__Family medical history (diseases, which
may be hereditary or w/increased risk of
occurrence)
__Social (relationships, diet, exercise,
occupation, and so on)
Complete:
specifics of at
least two history
areas
documented
Determining the Type of Examination (Tbl 7.4)
Components of an Examination (Using ’97 Guidelines)
Examination Component
Body Areas
__Head, face
__Neck
__Chest, breasts
__Abdomen
__Genit, groin
__Back, spine
__Each extremity
Organ Systems
__Const (vitals, gen'l appearance)
__Eyes
__GU
__ENT, mouth
__Skin
__Respiratory
__Integumentary
__Cardiovascular
__MS
__Gastrointestinal
__Neurological
__Lymph/hem/immun __Psychiatric
ProblemFocused
Expanded
ProblemFocused
1-5
elements
identified
by a bullet
At least 6
elements
identified by a
bullet
Detailed
Comprehensive
At least 2 elements
id’d by a bullet from
each of 6 aba/os
OR
at least 12 elements
id’d by a bullet in 2 or
more aba/os
All elements id’d
by a bullet in at
least 9 aba/os
and document at
least 2 elements
id’d by a bullet
from each of 9
aba/os
Chapter 7 (p. 193)
Evaluation and Management
Page | 4
Determining the Type of Examination (Tbl 7.4)
Components of an Examination (Text version (’95 Guidelines?))
Examination Component
Body Areas
__Head, face
__Neck
__Chest, breasts
__Abdomen
__Genit, groin
__Back, spine
__Each extremity
Organ Systems
__Const (vitals, gen'l appearance)
__Eyes
__GU
__ENT, mouth
__Skin
__Respiratory
__Integumentary
__Cardiovascular
__MS
__Gastrointestinal
__Neurological
__Lymph/hem/immun
__Psychiatric
ProblemFocused
1 body area
or system
Expanded
ProblemFocused
2-4 body syst
or
2-7 basic
systems,
including
affected area
Detailed
Comprehensive
2-7 detailed
systems,
including
affected area
8+ systems