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:
|Expanded Problem Focused||Brief
4 or more items
1 PFSH area
4 or more items
10 or more systems ("all others negative")
2 or 3 PFSH areas
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:
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)
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)|
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 X||Points =||Score|
|Self-limited or minor (stable, improved, worsening||Max=2||1||
|Established problem (stable or improved)||1|
|Established problem (worsening||2|
|New problem, no additional workup planned||Max=1||3|
|New problem, additional workup planned||4|
|Total Score =|
Risk of Complications and/or Mortality/Morbidity
|Level of Risk||Presenting problem(s)||Diagnostic procedure(s) ordered||Management options selected|
Amount/Complexity of Data Reviewed
|Categories of Data to be Reviewed||Points|
|Review and/or order clinical lab tests||1|
|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 Type||Number Diagnoses/ Management Options||Risk of Complications and/or Morbidity/Mortality||Amount/Com-plexity of Data Reviewed|
|Straightforward||Minimal 1||Minimal||Minimal or low 1|
|Low Complexity||Limited 2||Low||Limited 2|
|Moderate Complexity||Multiple 3||Moderate||Moderate 3|
|High Complexity||Extensive 4||High||Extensive 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
|History||Not applicable||Problem focused||Expanded problem focused||Detailed||Comprehensive|
|Examination||Not applicable||Problem focused||Expanded problem focused||Detailed||Comprehensive|
|Decision Making||Not applicable||Straightforward||Low Complexity||Moderate Complexity||High Complexity|
|Code||99211 (5 min)||99212 (10 min)||99213 (15 min)||99214 (25 min)||99215 (40 min)|
New Office Patient Codes
|History||Problem focused||Expanded problem focused||Detailed||Comprehensive||Comprehensive|
|Examination||Problem focused||Expanded problem focused||Detailed||Comprehensive||Comprehensive|
|Decision Making||Straightforward||Straightforward||Low Complexity||Moderate Complexity||High Complexity|
|Code||99201 (10 min)||99202 (20 min)||99203 (30 min)||99204 (45 min)||99205 (60 min)|