Evaluation and Management Services
Determining the Level of an Office Visit

An explanation of E&M Services, and how you can determine the level of an office visit...

A major component of many doctor's visits are E&M, or Evaluation and Management services. These codes describe the physical examination components of a doctor's visit.

If you work for any type of primary care physician as a coder, you understand that these codes are practically inescapable.

Because they're so important to so many doctor's offices and hospitals, it's important to make sure you fully understand how to code E&M services correctly.

Not only do you have to know exactly which ones to use and how, but you also have to know the correct level of service to bill for.

Classification of E&M Services

E&M services range from outpatient doctor visits to hospital exams to consultations

Evaluation and Management services range from outpatient doctor visits to hospital exams to consultations. But determining the right one always follows the same basic format:

  1. Identify your code set: This is the description of the service
  2. Identify the place and type of service: Where did the service take place (inpatient or outpatient) and what kind of service was it (office consultation or physical examination)
  3. Define the content of the service: The extent of the exam or consultation. This is the level of the E&M service
  4. Define the nature of the problem: Usually associated with the level of the service
  5. Check the time required to complete the service: How long did it take?

By using the above categories, you can assign an appropriate E&M code to any evaluation and management service.

New or established patient

There are many factors to consider when assigning an E&M code.

One of these factors is whether or not you have seen the patient before.

If you've never seen the patient before, you'll code a different level of E&M service. This indicates that the doctor had to spend extra time reviewing the patient's medical history and any presenting problems, since the doctor had never examined the patient or his medical records before.

If the patient has already been seen by the doctor, but it has been over three years since his or her last visit, you still code as a new patient. This is on the assumption that three years is long enough for any new medical problems or medical history to present themselves.

A doctor

Established patients usually require less time spent in the office, going over pertinent medical records or physical examinations.

Because of this, medical coders use a different category of E&M services, reserved for established patients.

Accordingly, insurance companies usually reimburse more for new patient services due to the extra work required. They pay less for office visits for established patients.

Certain distinctions do apply to these rules, however: new and established patients are not distinguished in the emergency room setting, and in certain other instances.

What is the "level" of an E&M service?

"How can there be different levels of an E&M service?" you may have asked. But this is easy to understand...

Sometimes, patients come in with simple diagnoses, such as ear infections. If:

  • these patients are already established
  • they regularly see the doctor
  • the complaint is simple
  • and the physical exam is very straightforward...

...the doctor will probably only code for a minimal office visit.

This means that you charge a lower level E&M service, with a correspondingly smaller charge amount to the insurance company.

On the other hand, if:

  • the patient comes into the office with a severe headache caused by an indistinguishable bacteria and
  • the doctor must perform an extensive physical examination, including spending an extended amount of time with the patient, counseling the patient and performing many laboratory tests...

...the evaluation and management code will be much higher.

This means that the E&M service code is much higher, with a correspondingly high charge amount.

Components of an E&M service

There are many requirements of an evaluation and management service...

There are many requirements of an evaluation and management service...

  • Chief complaint: The reason the patient came into the office, stated in the patient's own words.

  • Counseling: The discussion with the patient. This component includes a discussion of the diagnosis, prognosis, instructions for management, and patient education.

  • Family history: A review of any significant family history, which may affect the patient's medical condition.

  • History of present illness: A description of the patient's present illness, listed chronologically.

Determining the level of the E&M service

There are certain components, the extent of which determines the level of the evaluation and management service:

  • History
  • Examination
  • Medical decision making
  • Counseling
  • Coordination of care
  • Nature of presenting problem
  • Time

The first three of these components (History, Examination, Medical Decision Making) are considered the "key" components in selecting a level of E&M service. The extent of these services are major factors in defining the level of the service performed.

The other three factors (Counseling, Coordination of Care, Nature of Presenting Problem) are contributing factors. Although they all contribute to the extent of the E&M service, they aren't necessary components of each evaluation and management visit.

The last component (Time) is included to help providers determine the level of an office visit.

For more information on determining the level of the evaluation and management service, please see the Evaluation and Management section of your current CPT codebook.

No matter what level of E&M service your provider codes, it's likely that determining whether or not this is the right code will come up before long. It's difficult to determine the extent of some exams, especially if they're included in other multiple procedures.

Following the above rules will help, but make sure you have a complete understanding of how the components of an evaluation and management service combine together to create a complete physical exam.

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