The following information is accurate for Dates of Service PRIOR to March 1, 2021. For information on determining the correct E/M for Dates of Service on and after March 1, 2021 please see How to Determine the Correct E/M Code DOS On and After 3/1/2021.
To determine appropriate coding for Evaluation and Management (E&M) services for Dates of Service prior to 3/1/21 use either the 1995 or 1997 edition of CMS’ Documentation Guidelines for Evaluation and Management Services. The following outlines the overlap of both of these documents.
The descriptors for the levels of E/M services recognize seven components used in defining the levels of reported E/M service. The following lists the seven components:
- History (Key)
- Examination (Key)
- Medical decision making (Key)
- Counseling
- Coordination of care
- Nature of presenting problem
- Time
When selecting the level of E/M services, the first three components are designated as key components. In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service.
Key Components
E/M service is dependent on two of three key components. Performance and documentation of one component (eg, examination) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service.
1. History (Key)
The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history all three elements in the table must be met. (A chief complaint is indicated at all levels.)
2. Examination (Key)
The levels of E/M services are based on four types of examination:
- Problem Focused - a limited examination of the affected body area or organ system.
- Expanded Problem Focused - a limited examination of the affected body part or organ system and any other symptomatic or related body area(s) or organ system(s).
- Detailed - an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).
- Comprehensive - a general multi-system examination or complete examination or a single organ system and other symptomatic or related body area(s) or organ system(s).
3. Medical Decision Making (Key)
The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.
Other Components
Time
In the case of visits which consist predominantly of counseling or coordination of care (more than 50%), time is the key or controlling factor to qualify for a particular level of E/M service.
The total length of time of the encounter (faced-to-face) should be documented and the record should describe the counseling and/or activities to coordinate care.
CMS Reference
1995 Documentation Guidelines for Evaluation and Management Services
1997 Documentation Guidelines for Evaluation and Management Services
Division of Workers’ Compensation Websites
DWC Official Medical Fee Schedule
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