Understanding Evaluation and Management Criteria
- Getting Back to Basics

Refer to AMA CPT Assistant November 2008/Volume 18 Issue 11 for Coding Evaluation and Management Documentation Guidelines as well as CMS 1995 & 1997 Documentation Guidelines which are currently in use. Physicians may utilize either 95 or 97 Guidelines whichever is more advantageous.

Crucial reminder: Physicians are ultimately responsible and will be held accountable for their documentation and capture of the E/M level assignment. The physician’s documentation must support through medical necessity the level of service reported/charged. Be careful of electronic documentation systems, they can lead physicians and clinicians to higher levels of service, which may not be appropriate. Physicians must be familiar with the guidelines prior to utilizing electronic programmed prompts and templates.

The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. These components are:

  • history
  • examination
  • medical decision making
  • counseling
  • coordination of care
  • nature of presenting problem
  • time

The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services.

Documentation of the Patient’s History

CHIEF COMPLAINT (CC)

The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. The medical record should clearly reflect the chief complaint.

HISTORY OF PRESENT ILLNESS (HPI)

The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

  • location
  • quality
  • severity
  • duration
  • timing
  • context
  • modifying factors
  • associated signs and symptoms

REVIEW OF SYSTEMS (ROS)

A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced

For purposes of ROS, the following systems are recognized:

  • Constitutional symptoms (e.g., fever, weight loss)
  • Eyes
  • Ears, Nose, Mouth, Throat
  • Cardiovascular
  • Respiratory
  • Genitourinary
  • Musculoskeletal
  • Integumentary (skin and/or breast)
  • Neurological
  • Psychiatric
  • Endocrine
  • Hematologic/Lymphatic
  • Allergic/Immunologic

The patient's positive responses and pertinent negatives for the system(s) related to the problem should be documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, each system(s) must be individually documented.

PAST, FAMILY and/or SOCIAL HISTORY (PFSH)

The PFSH consists of a review of three areas:

  • past history (the patient's past experiences with illnesses, operations, injuries and treatments)
  • family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk)
  • social history (an age appropriate review of past and current activities)

For the categories of subsequent nursing facility care, CPT requires only an "interval" history. PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI.

DOCUMENTATION OF PHYSICAL EXAM COMPONENTS

General Multi-System Exam Or Single Organ Systems

  • Constitutional (e.g., vital signs, general appearance)
  • Eyes
  • Ears, nose, mouth and throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Skin
  • Neurologic
  • Psychiatric
  • Hematologic/lymphatic/immunologic

The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.

DOCUMENTATION OF MEDICAL DECISION MAKING (MDM)

The levels of E/M services recognize four types of medical decision making (straight-forward, low complexity, moderate complexity and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

  • the number of possible diagnoses and/or the number of management options that must be considered
  • the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed
  • Ears, nose, mouth and throat
  • the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.