1. CPT Evaluation and Management
Chapter 9
CPT Evaluation and Management

2. E/M Section Codes 99201–99499 First section in CPT
Review guidelines at beginning section
Apply applicable notes

3. E/M Coding Tips
Notes located beneath headings and/or subheadings apply to all codes in heading or subheading
Parenthetical notes located below a specific code apply to that code only
Unless the note indicates otherwise

4. E/M Overview Introduced in 1992
Between three and five levels of service
Reflects amount of work involved in providing health care to a patient

5. Levels of Service Organized according to: Place of service
Physical location where health care is provided to patients (e.g., office, hospital, home, nursing facility)
Type of service
Type of health care services provided to patients (e.g., new or initial encounter, follow-up or subsequent encounter, consultation)

6. Example
Dr. Miller completed Jennifer Sullivan’s history and physical on the first day of her inpatient admission
Place of service: hospital
Type of service: initial care
E/M category: hospital inpatient services
E/M subcategory: initial hospital care

7. E/M Section Guidelines
Located at beginning of section
Includes:
Classification of E/M services
Definitions of commonly used terms
Unlisted service
Special report
Clinical examples
Instructions for selecting level of E/M service

8. Classification of E/M
Categories (e.g., office, outpatient visits, consultations)
Subcategories (e.g., new and established patients)
Five-digit numerical codes (99201–99499)
(continued)

9. Classification of E/M Code descriptions include:
Place and/or type of service
Content of service
Detailed history and examination
Nature of presenting problem
Time required to provide service

10. E/M Key Terms New patient Established patient Concurrent care
Unlisted service
Special report
Clinical examples (Appendix C)

11. Levels of E/M Service
When selecting, require key components of history, examination, and medical decision making
Contributory components include counseling, coordination of care, nature of presenting problem, and time

12. Key Components Three components: New patients Established patients
Extent of history
Extent of examination
Complexity of medical decision making
New patients
Three components required
Established patients
Two of three components required

13. Extent of History Includes: Four types:
History of present illness (HPI)
Review of systems (ROS)
Past/Family/Social history (PFSH)
Four types:
Problem-focused
Expanded problem-focused
Detailed
Comprehensive

14. Extent of Examination Four types: Problem-focused
Expanded problem-focused
Detailed
Comprehensive

15. Complexity of Medical Decision Making
Measured by:
Number of diagnoses or management options
Amount and/or complexity of data
Risk of complications and/or morbidity or mortality
(continued)

16. Complexity of Medical Decision Making
Documentation includes:
Ancillary test results (e.g., laboratory)
Known diagnoses
Opinions of other physicians
Planned course of action
Review of previous records

17. Medical Decision Making
Four types of complexity:
Straightforward
Low
Moderate
High

18. Medical Decision Making
E/M Code Selection
Current Procedural Terminology © 2008 American Medical Association. All rights reserved.
Select E/M code based on extent of history and examination and complexity of medical decision making
History
Problem- focused
Expanded problem-
focused
Expanded problem-focused
Detailed
Compre-hensive
Examina-tion
Expanded problem- focused
Medical Decision Making
Straight- forward
Low complexity
Moderate complexity
Moderate Complexity
High Complexity
Go to appropriate E/M category/subcategory and select code based on this information

19. Contributory Components
Counseling and/or coordination of care components “drive” CPT code selection only when they dominate the encounter.

20. Counseling Diagnostic results Prognosis
Risks and benefits of treatment options
Instructions for treatment and/or follow-up
Compliance with treatment options
Risk factor reduction
Patient and family education

21. Nature of the Presenting Problem
Five types:
Minimal
Self-limited or minor
Low severity
Moderate severity
High severity

22. Time Face-to-face time Unit/Floor time
Amount of time office or outpatient care provider spends with patient and/or family
Unit/Floor time
Amount of time provider spends at patient’s bedside and managing patient’s care on unit/floor

23. Billing According to Length of Time
Document:
Total length of time for the encounter
Length of time spent coordinating and/or counseling
Issues discussed
Relevant history, exam, and medical decision making

24. Code 99211
Nurse visit
Reported when ancillary personnel provide E/M services
Document chief complaint and description of service provided

25. Hospital Observation Services
Subcategories
Observation care discharge services
Initial observation care
Discharge services
Final examination of patient
Discussion of hospital stay
Instructions for continuing care

26. Initial Observation Care
Reported for patients who are admitted for observation services on one date and discharged from observation status on a different date

27. Hospital Inpatient Services
Subcategories
Initial hospital care
Subsequent hospital care
Observation or inpatient care services
Hospital discharge services

28. Hospital Discharge Services
Includes:
Final examination of patient
Discussion of hospital stay
Instructions for continuing care
Preparation of discharge records, prescriptions, and referral forms

29. Consultations Consultation criteria Subcategories
Office or other outpatient services
Initial inpatient consultations
Preoperative clearance

30. Pediatric Critical Care Patient Transport
Definition
Interfacility transport
Critical illness or injury

31. Critical Care Services
Physician directly delivers medical care to critically ill or injured patient
Manages life-threatening conditions
Single or multiple vital organ system failure
Does not have to be provided in a critical care unit
May be continuous or interrupted
(continued)

32. Critical Care Services
Includes the following procedures:
Blood gases
Chest x-rays
Gastric intubation
Information data stored in computers
Cardiac output measurements
Pulse oximetry
(continued)

33. Critical Care Services
Includes the following procedures:
Temporary transcutaneous pacing
Vascular access procedures
Ventilatory management

34. Inpatient Neonatal and Pediatric Critical Care
Neonate
Low birth weight
Less than 1500 grams (g)

35. Nursing Facility Services
Includes:
Nursing facility (NF)
Skilled nursing facility (SNF)
Intermediate care facility (ICF)/Mentally retarded
Long-term care facility (LTCF)
Psychiatric residential treatment facility

36. Prolonged Services Reported in addition to an E/M service at any level
Physician’s services involving patient contact that are considered beyond the usual service in either an inpatient or outpatient setting
(continued)

37. Prolonged Services Reported only when time is greater than 30 minutes
Time must be documented

38. Physician Standby Services
Physician spending a prolonged period of time without patient contact waiting for an event to occur that will require the physician’s services
(continued)

39. Physician Standby Services
Standby types:
Operative
Pathology
Diagnostics
Obstetrics
Pediatrics

40. Case Management Services
Physician is responsible for:
Direct care of patient
Coordinating and controlling access to or initiating and/or supervising other health care services needed

41. Care Plan Oversight Services
Cover physician’s time while supervising a complex and multidisciplinary care treatment program for a specific patient under the care of a home health agency, hospice, or nursing facility

42. Preventive Medicine Services
Routine examinations or risk management counseling for children and adults who exhibit no overt signs or symptoms of a disorder while presenting to the medical office for a preventive medical physical
Wellness visits
Risk factors

43. Newborn Care
Service provided in a variety of health care settings, hospitals, birthing centers, and homes that include:
History and examination of normal infant
Attendance at delivery and initial stabilization of newborn
Newborn resuscitation

44. Counseling Risk Factor Reduction
Preventive Medicine Counseling ( )
Used for promoting health and preventing illness and injury
(continued)

45. Counseling Risk Factor Reduction
Intervention should address family problems, diet and exercise, substance use, injury prevention, and dental health
No illness should be present with these codes

46. Behavior Change Intervention
For patients who have behavior that is considered an illness, itself
Smoking and tobacco cessation
Alcohol and/or substance abuse

47. Non-Face-to-Face Physician Service
Telephone Service ( )
E/M service provided by a physician using the telephone
(continued)

48. Non-Face-to-Face Physician Service
Code is not reported if service ends with decision to see patient within 24 hours or within seven days of a previously completed procedure
Provided to an established patient

49. Special E/M Services Provided to:
Establish baseline information prior to issuance of life or disability insurance certificates
Examine a patient with a work-related or medical disability problem