POLICY:
EVALUATION AND MANAGEMENT: GENERAL GUIDELINES
Policy Number: FIN – 2100
Page(s): 1 of 2
Approved by:
Effective Date:
PURPOSE: Evaluation and Management Services are some of the most misused and
improperly coded services utilized in all healthcare practices.
POLICY: Follow 1995 Guidelines for coding E/M Services to ensure that all services
are properly documented and that documentation supports the level of service that is
billed to insurance carriers.
New Patient
 Any patient who has not been seen in the practice in the previous three years by a
physician of the same specialty
 Codes 99201 through 99205
Established Patient
 Any patient who returns to the office that HAS been treated by a physician of the
same specialty within the past three years.
 Codes 99211 through 99215
Seven Components of E/M Services
1. History
2. Examination
3. Medical Decision Making
4. Counseling
5. Coordination of Care
6. Nature of Presenting Illness
7. Time (least important in determining level of service)
Key Components are the History, Examination, and Clinical Decision Making as these
are the primary factors used to determine the level of service to be billed for.
When coding for E/M services, the charts and decision making tool on the following
pages will be utilized, depending on whether the service is for a “new” or “established”
patient.
Evaluation and Management Decision Tool
NOTE: This tool is based on 1995 Documentation Guidelines for Evaluation and Management
Services (DGs) by CMS.
New Patient – Patient is new to your office or has NOT been seen in the past 3 years by you or someone
else in your practice with the same specialty or subspecialty. ALL E/M code levels require a Chief
Complaint.
E/M Code
History (Requires 3 of 3)
Exam
MDM
Time
Level
HPI
ROS
PFSH
1-3
N/A
N/A
1
Straightforward
10+ min
99201
1-3
1
N/A
2-7
Straightforward
20+ min
99202
4+
2-9
1
2x-7x
Low
30+ min
99203
4+
10+
3
8+
Moderate
45+ min
99204
4+
10+
3
8+
High
60+ min
99205
NOTE: Requires 3 of 3 key factors (History, Exam, MDM) to be met or exceeded. Time is ONLY
considered the determining key factor when 50% or more is spent on counseling and/or coordination of
care and documented appropriately.
Established Patient – You, or someone else in your practice with the same specialty or subspecialty have
seen the patient in the past 3 years. ALL E/M code levels require a Chief Complaint.
E/M Code
History (Requires 2 of 3)
Exam
MDM
Time
Level
HPI
ROS
PFSH
N/A
N/A
N/A
N/A
N/A
5+ min
99211
1-3
N/A
N/A
1
Straightforward
10+ min
99212
1-3
1
N/A
2-7
Low
15+ min
99213
4+
2-9
1
2x-7x
Moderate
25+ min
99214
4+
10+
2+
8+
High
40+ min
99215
NOTE: Requires 2 of 3 key factors (History, Exam, MDM) to be met or exceeded. Time is ONLY
considered the determining key factor when 50% or more is spent on counseling and/or coordination of
care and documented appropriately.
HISTORY
History of Present Illness (HPI) Elements
A chronological description of the development of the patient’s present illness from the first sign and/or
symptom or from the pervious encounter to the present. It includes:
Location Quality, Severity, Duration, Timing, Context, Modifying Factors, and Association Signs and
Symptoms.
Review of Systems (ROS) Elements
An inventory of body systems obtained through a series of questions seeking to identify signs and/or
symptoms, which the patient may be experiencing or has experienced. The following systems are
recognized:
Constitutional (e.g. fever, weight loss), Eyes, Ears/Nose/Mouth/Throat, Cardiovascular, Respiratory,
Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary (skin and/or breast), Neurological,
Psychiatric, Endocrine, Hematologic/Lymphatic, Allergic/Immunologic
Past, Family, and/or Social History (PFSH) Elements
PFSH consists of a review of 3 areas:
1. Past history (patient’s past experiences with illnesses, operations, injuries,
and treatments);
2. Family History (review of medical events in patient’s family, including
diseases which may be hereditary or place the patient at risk); and
3. Social History (age appropriate review of past and current activities)
EXAMINATION
For purposes of examination, the following body areas are recognized:
Head (including face), Neck, Chest (including breast and axilla), Abdomen, Genitalia/Groin/Buttock,
Back (including spine), Each Extremity
For purposes of examination, the following organ systems are recognized:
Eyes, Ears/Nose/Mouth/Throat, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary,
Musculoskeletal, Skin, Neurologic, Psychiatric, Hematologic/Lymphatic/Immunologic
COMPLEXITY of MEDICAL DECISION MAKING (MDM)
The levels of E/M services recognize four types of MDM (straightforward, low complexity, moderate
complexity, and high complexity) and require 2 of 3 elements listed below to be met or exceeded:
1. Number of possible Diagnoses and/or number of management options that
must be considered;
2. Amount and/or complexity of medical records, diagnostic tests, and/or
other information that must be obtained, reviewed and analyzed; and
3. Risk of significant complications, morbidity and/or mortality as well as
comorbidities, associated with the patient’s presenting problem(s), the
diagnostic procedure(s) and/or the possible management options.