1. 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
UNC SOM Compliance

2. E&M Services Classifications – most common
Outpatient - clinic visits
Consult
New
Established
Inpatient – hospital visits
Initial
Subsequent
Consult, initial and follow-up

3. Medicare Outpatient E & M
Approximate Allowables
Outpatient Visit Category
CPT Code Level
Established
New
Consultation 1
$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
$201.00

4. 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

5. 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

6. 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

7. 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

8. Levels of Service

9. Defining Levels of Service
History
Physical Examination
Medical Decision Making
Other Considerations
Time
Counseling
Coordination of Care
Nature of Presenting Problem

10. History – Three Parts
History of Present Illness
Review of Systems
Past, Family and Social History

11. History of the Present Illness (HPI)
Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated signs and symptoms

12. Two Levels of HPI
Brief = 1-3 elements described
Extended = 4+ elements described OR
Status of at least 3 chronic or inactive conditions
“Mr. Peters has for two weeks felt a sharp pain in his left shoulder when he raises his arm.”
Duration
Quality
Location
Context

13. 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
Musculoskeletal
Integumentary (including breasts)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic

14. 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

15. Past, Family and Social History (PFSH)
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
Living arrangements
Marital status
Drug or tobacco use
Occupational/educational history

16. 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

17. 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

18. History Example
2 y/o male c/o vomiting/diarrhea & 2 day fever. Diarrhea watery for 4 days, temp Vomited 2X this a.m.,  appetite. Started Pedialyte 3 days ago. Drank several oz Pedialyte this a.m. Ø rhinorrhea, Ø cough, Ø daycare

19. History Example
2 y/o male c/o vomiting/diarrhea & 2 day fever. Diarrhea watery for 4 days, temp Vomited 2X this a.m.  appetite. Started Pedialyte 3 days ago. Drank several oz Pedialyte this a.m. Ø rhinorrhea, Ø cough, Ø daycare
bchief complaint
b HPI duration
b HPI quality
b HPI severity
b HPI modifying factors

20. Ø rhinorrhea, Ø cough, Ø daycare
History Example
2 y/o male c/o vomiting/diarrhea & 2 day fever. Diarrhea watery for 4 days, temp Vomited 2X this a.m.  appetite. Started Pedialyte 3 days ago. Drank several oz Pedialyte this a.m.
Ø rhinorrhea, Ø cough, Ø daycare
b ROS GI
b ROS EENT
b ROS Resp
b PFSH Social

21. 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 99214
new patient or 99203, 99243

22. 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.

23. 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.

24. 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

25. 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
At least 6 elements
One or more organ/body system
Detailed
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

26. General Multi-system Examination (1997 Guidelines)

27. 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

28. Medical Decision Making (MDM)
Based on any two of the following:
Number of Diagnostic and/or Management Options
Amount and Complexity of Data
Risk

29. 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)

30. 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)

31. 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.

32. Table of Risk Risk Level Presenting Problem(s)
Diagnostic Procedure(s) Ordered
Management Options Selected
Minimal
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
Low
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
Moderate
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
High
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 de-escalate care because of poor prognosis

33. Level of Medical Decision Making Documented
Four levels:
Straightforward
Low complexity
Moderate complexity
High complexity
Two of the three areas:
dx options, amount of data, risk establish the MDM level
Diag/mgt options
0-1 2 3 4
Amount of data
Overall risk
Minimal
Low
Moderate
High
Level of MDM
Strghtfwd

34. 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.

35. New Outpatient Visits/Consults
Level
History
Exam
MDM
99201, 99241
Problem Focused (PF) PF
Straightforward
99202, 99242
Expanded prob focused (EPF)
EPF SF
99203, 99243
Detailed
Low
99204, 99244
Compr.
Moderate
99205, 99245
High

36. Established Outpatient Visits
Level
History
Exam
MDM
99211
N/A
99212 PF SF
99213
EPF
Low
99214
Detailed
Moderate
99215
Compr.
High

37. Initial Hospital/Observation
Level
History
Exam
MDM
99221, 99218
Detailed
SF/Low
99222, 99219
Compr.
Moderate
99223, 99220
High

38. Subsequent Hospital and Follow-up Consults
Level
History
Exam
MDM
99231, 99261 PF
SF/LOW
99232, 99262
EPF
Moderate
99233, 99263
Detailed
High

39. 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

40. Time as the Controlling Factor
Established patient
New patient, Consultation
Approximate time
99211
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

41. 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

42. 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.

43. 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.

44. 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.

45. 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.

46. 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.

47. 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.

48. Where To Get Help www.med.unc.edu/compliance/
UNC P&A Professional Charges
School of Medicine Compliance Office
Confidential Help Line
AMA CPT Manual