Corporate

May 10, 2012 - Revised: 04.26.17

Evaluation and Management Services (E/M): Requirements of Key Elements

Recently, CGS has received questions concerning the requirements for the key elements (history, physical exam, and medical decision making) for Evaluation & Management (E/M) services involving established patients. Discussion around the requirement of a physical exam has prompted the need for clarification of documentation requirements.

Per the CPT E/M parenthetical guidelines:

Definitions of Commonly Used Terms:

  • “The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the levels of E/M services. The first three components (history, examination, and medical decision making) are considered the key components in selecting the level of E/M services. An exception to this rule is in the case of visits that consist predominantly of counseling or coordination of care"

Instruction for Selecting a Level of E/M Service:

  • The extent of the history/exam is dependent upon clinical judgment and on the nature of the presenting problem(s)
  • Medical Decision Making refers to the complexity of establishing a diagnosis and/or selecting a management option

Selecting the Appropriate Level of E/M Service:

  • For categories/subcategories, all of the key components; ie, history, exam and medical decision making must meet or exceed the stated requirements to qualify for a particular level of E/M service
  • For categories/subcategories, two of the three key components (history, exam, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M services; established..." Medical decision making (at any level) refers to the complexity of establishing a diagnosis and/or selecting a management option.

In support of this requirement, CPT and CMS indicate E/M code selection requires the inclusion of face-to-face services.

  • CPT Professional edition states: “solely for the purpose of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s)".

References:


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