July 1997 Bulletin

HCFA, AMA tell how to code for E/M

Guidelines on documentation for key components

As part of its ongoing efforts to prevent fraud and abuse in the Medicare program, the Inspector General (IG) of the Department of Health and Human Services is conducting audits of teaching hospitals and private physician practices. One of the issues raised during these audits is "upcoding," especially for evaluation and management (E/M) services.

The Health Care Financing Administration (HCFA) and the American Medical Association (AMA) have developed documentation guidelines to assist physicians in selecting the appropriate level of E/M service.

E/M services include three key components: history, physical examination and medical decision-making. The complexity of these three components determines which level of E/M service may be coded.


There are four elements of the patient history: chief complaint, history of present illness (HPI), review of systems (ROS), and past, family, and/or social history (PFSH).

Documentation of the chief complaint should identify the reason for the encounter (e.g., symptom(s), problem(s), diagnosis, condition, patient's words, or return visit).

The HPI should indicate the location/site(s), quality (e.g., sharp, dull, throbbing), severity (minor, moderate, severe), duration, timing (with exercise, at night), context (worsening, recurrent), the modifying factors (rest, heat, limb elevation) and the associated signs and symptoms of the problem.

The ROS includes the following factors: constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, endocrine, hematologic/lymphatic, allergic/immunologic and "all others negative."

The past medical, family and social history includes documentation of past medical history (illnesses, operations, injuries, treatments), family history (medical events, heredity, patient at risk) and social history (marital status, occupation, habits, sexual history).

The level of the history performed is calculated by the number of items documented for each element:

Problem FocusedBrief
1-3 items
Expanded Problem FocusedBrief
1-3 items
to problem
1 system
4 or more items
2-9 systems
1 PFSH area
4 or more items
10 or more systems ("all others negative")
2 or 3 PFSH areas

Physical examination

Documentation requirements for the physical examination are more problematic. Guidelines on documenting a comprehensive multisystem examination have been released by HCFA, but these are difficult for many specialists to meet. In order to allow specialists to bill for a comprehensive physical exam, HCFA and the AMA have asked the specialty societies to develop guidelines for a comprehensive single system exam. The Academy and other specialty societies have complied with this request; however, these guidelines have not yet been released by HCFA. Therefore, changes to the information given below are still possible.

HCFA has defined twelve organ systems: constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric and hematologic/lymphatic/immune.

Within the musculoskeletal organ system, there are six body areas: neck (including cervical spine and head), thoracic-lumbar spine/ribs/pelvis, and the right and left lower and upper extremities.

To document a comprehensive musculoskeletal examination, positive and relevant negative findings of the following exam elements must be noted. The number of items required is indicated in parentheses.


Vascular Organ System:

Lymphatic System:

Musculoskeletal System (Joints, Muscles and Bones): (each item must be recorded)

Neurological/Psychiatric Systems (Higher Cortical Functions, Peripheral Nerves, Coordination): (each item must be recorded)

Skin System:

To determine the level of examination performed, choose from the descriptions in the table below. For a comprehensive exam, all findings must be documented, both positive and relevant negative elements.

Problem Focused Limited to affected body area or organ system (e.g., portion of body area such as a fingertip)
Expanded Problem Focused Affected body area or organ system and other symptomatic or related organ systems (e.g., portion of body area plus other symptomatic organ system such as musculoskeletal and neurologic)
Detailed Extended exam of affected body area(s) and other symptomatic or related organ systems (complete single body area exam)
Comprehensive Complete single specialty exam (all elements recorded for 4 of 6 musculoskeletal body areas) or complete multispecialty exam (8 of 12 organ systems)

Medical decision-making

There are three elements of medical decision-making: number of diagnoses or management options, risk of complications and/or morbidity or mortality and the amount and complexity of the data reviewed.

Number of Diagnoses/Management Options

Categories for Problems or Major New Symptoms Number XPoints = Score
Self-limited or minor (stable, improved, worsening Max=21
Established problem (stable or improved)
Established problem (worsening
New problem, no additional workup plannedMax=1 3
New problem, additional workup planned

Total Score =

Risk of Complications and/or Mortality/Morbidity

Level of RiskPresenting problem(s) Diagnostic procedure(s) orderedManagement options selected
  • One self-limited or minor problem (e.g., suture removal/laceration)
  • Laboratory tests requiring venipuncture
  • Rest
  • Elastic bandages
  • Superficial dressings
  • Two or more self-limited or minor problems
  • One stable chronic illness
  • Acute uncomplicated illness or injury (e.g., simple sprain)
  • Superficial needle biopsies
  • Clinical laboratory tests requiring arterial puncture
  • Single area X-rays
  • OTC drugs
  • Minor surgery with no identified risk factors
  • Physical/occupational therapy
  • One or more chronic illnesses with mild exacerbation
  • Two or more stable chronic illnesses
  • Acute illness with systemic symptoms
  • Acute complicated injury
  • Physiologic tests under stress
  • Multiple area X-rays
  • Deep needle or incisional biopsy
  • Obtain fluid from body cavity (e.g., joint, bursa, lumbar puncture)
  • CT, MRI, bone scan
  • Minor surgery with identified risk factors
  • Elective major surgery (open, percutaneous, endoscopic)
  • Prescription drug management
  • Closed treatment of fracture/disloca-tion without manipulation
  • One or more chronic illnesses with severe exacerbation
  • Acute or chronic illness or injuries that pose a threat to life or bodily function (e.g., multiple trauma, pulmonary embolus)
  • An abrupt change in neurologic status (e.g., weakness or sensory loss)
  • Discography
  • Myelography
  • Arthrogram
  • Elective major surgery (open, percutaneous, endoscopic) with identified risk factors
  • Emergency major surgery (open, percutaneous, endoscopic)
  • Parenteral controlled substances
  • Drug therapy requiring intensive monitoring for toxicity

Amount/Complexity of Data Reviewed

Categories of Data to be ReviewedPoints
Review and/or order clinical lab tests1
Review and/or order of tests in radiology section of CPT (includes nuclear medicine) 1
Review and/or order of tests in medicine section of CPT (e.g., EMG, SSEP, noninvasive vascular studies, pulmonary function studies, psychological testing) 1
Discussion of test results with performing physician 1
Decision to obtain old records and/or history from someone other than patient 1
Review and summarization of old records and/or obtaining history from someone other than patient, and/or discussion of case with another health care provider 2
Independent visualization of image, tracing or specimen itself (not simply review of report) 2

The level of medical decision making is based on the scores of the three elements, as determined below.

Decision Making TypeNumber Diagnoses/ Management Options Risk of Complications and/or Morbidity/Mortality Amount/Com-plexity of Data Reviewed
StraightforwardMinimal 1 MinimalMinimal or low 1
Low ComplexityLimited 2 LowLimited 2
Moderate ComplexityMultiple 3 ModerateModerate 3
High ComplexityExtensive 4 HighExtensive 4

To select the appropriate level of E/M service, use the findings from the history, examination and decision-making sections above. Choose the appropriate code based on the column with the most circled items or average the items to make your decision.
The typical time is listed with each code as an example only.

Established Office Patient Codes

HistoryNot applicable Problem focusedExpanded problem focused DetailedComprehensive
ExaminationNot applicable Problem focusedExpanded problem focused DetailedComprehensive
Decision MakingNot applicable StraightforwardLow Complexity Moderate ComplexityHigh Complexity
Code99211 (5 min) 99212 (10 min)99213 (15 min) 99214 (25 min)99215 (40 min)

New Office Patient Codes

HistoryProblem focused Expanded problem focusedDetailed ComprehensiveComprehensive
ExaminationProblem focused Expanded problem focusedDetailed ComprehensiveComprehensive
Decision MakingStraightforward StraightforwardLow Complexity Moderate ComplexityHigh Complexity
Code99201 (10 min) 99202 (20 min)99203 (30 min) 99204 (45 min)99205 (60 min)

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