Mastering Evaluation and Management

Services in Healthcare
Mastering Evaluation and Management
Services in Healthcare

A Resource for Professional Services

Stacy Swartz, BSHIM, RHIA, CCS, CPC

Mastering Evaluation and Management Services in Healthcare: A Resource
for Professional Services

Copyright © Business Expert Press, LLC, 2021.

Cover design by Charlene Kronstedt

Interior design by Exeter Premedia Services Private Ltd., Chennai, India

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted in any form or by any
means—electronic, mechanical, photocopy, recording, or any other
except for brief quotations, not to exceed 400 words, without the prior
permission of the publisher.

First published in 2021 by

Business Expert Press, LLC
222 East 46th Street, New York, NY 10017
www.businessexpertpress.com

ISBN-13: 978-1-95253-866-7 (paperback)

ISBN-13: 978-1-95253-867-4 (e-book)

Business Expert Press Healthcare Management Collection

Collection ISSN: 2333-8601 (print)

Collection ISSN: 2333-861X (electronic)

First edition: 2021

10 9 8 7 6 5 4 3 2 1

Printed in the United States of America.

 Description
This book explores Evaluation and Management (E/M) coding and serves
as a resource in the practice and application of level of service codes.
For two decades the 1995 and 1997 guidelines have provided guid-
ance and structure around the documentation requirements necessary to
support professional, outpatient services. After twenty-three years, Medi-
care has announced the adoption of a new set of standards to be released
on January 1, 2021.
This book will serve as a guide for correct code assignment and as
an educational resource for the 1995, 1997 and 2021 documentation
guidelines.

Keywords
1995 Coding Guidelines; 1997 Coding Guidelines; 2021 Coding
­Guidelines; history of present illness; HPI; review of systems; ROI;
past; family; social history; PFSH; medical decision making; MDM;
examination; exam; documentation
 Contents

Chapter 1 Introduction���������������������������������������������������������������������1
Chapter 2 General Principles of Medical Record
Documentation����������������������������������������������������������������3
Chapter 3 Classification and Structure of the Evaluation and
Management System��������������������������������������������������������5
Chapter 4 1995 Documentation Guidelines�������������������������������������7
Chapter 5 1997 Documentation Guidelines�����������������������������������31
Chapter 6 Definitions of Commonly Used Terms���������������������������79
Chapter 7 2021 Documentation Guideline Changes�����������������������83

References���������������������������������������������������������������������������������������������93
About the Author����������������������������������������������������������������������������������95
Index���������������������������������������������������������������������������������������������������97
 CHAPTER 1

Introduction
Centers for Medicare & Medicaid Services (CMS) provides coders, phy-
sicians, and claim reviewers with guidance on acceptable documentation
standards for Evaluation and Management (E/M) services. E/M codes
were included in the Current Procedural Terminology (CPT) code book
in 1992. These codes were designed to classify services provided by phy-
sicians during office and hospital visits, skilled nursing facility visits, and
consultations. The various levels of the E/M codes describe the amount
of effort, time, responsibility, medical knowledge, and decision making
that physicians contribute to the prevention, diagnosis, and treatment of
medical illness and injuries. Health care facilities, such as hospitals, also
report E/M codes to designate encounters where outpatient services were
delivered.
In the hospital setting, E/M codes are allocated for emergency depart-
ment visits. E/M code assignment helps differentiate between medical
and surgical services when assigning patients to a specific payment group.
E/M code assignment also facilitates data collection for outpatient report-
ing by counting patients, rather than services. This is important because a
patient could have multiple outpatient services during a single visit. Con-
trary to the documentation guidelines set forth for professional services,
facility code assignment is unique to each individual hospital. Under the
prospective payment system, CMS directed hospitals to develop their
own method for assigning facility E/M codes.
In claims processing for physician services, E/M codes are reported to
document the care provided to each individual patient. Although medical
necessity is the overarching criterion, code assignment is dependent on
the documentation within the medical record.
Documentation guidelines were created to quantify the information
needed for each key component. These guidelines provided instruction
on the specific documentation requirements necessary to assign E/M
2 Mastering Evaluation and Management Services

codes for the varying levels of service. CMS released the first set of docu-
mentation guidelines in 1995.
In October 1997, the Health Care Finance Administration, which
is now CMS, and the American Medical Association jointly produced
­revisions to the 1995 Documentation Guidelines for Evaluation and
Management Services.
Although similar in most characteristics, the 1997 guidelines include
specific elements that should be performed and documented for gen-
eral multisystem and single-specialty examinations. Physicians may use
whichever set of guidelines is more advantageous, but they must strictly
use one or the other, per patient encounter.
For two decades, the 1995 and 1997 guidelines have provided guid-
ance and structure around the documentation requirements necessary
to support professional, outpatient services. After 23 years, Medicare
has announced the adoption of a new set of standards to be released on
­January 1, 2021.
 Index
Letter ‘t’ after page number indicates table.
acute and chronic illness, 89 Evaluation and Management
American Medical Association, 2, service sections, 5, 82
83, 89
Documentation Guidelines, 7. See also
Centers for Medicare & Medicaid Evaluation and Management
Services, 1, 2, 7, 31, 83 services
chief complaint (CC), 8, 9, 10, 32, 1995, 7
33, 34 documentation of coordination of
claim reviewers, 1 care, 29–30
coders, 1 documentation of counseling,
codes, 1, 83, 85 29–30
assignment, 1, 7 documentation of examination,
components, 78t 21–22
correct code assignment, factors, documentation of history, 8–21
7–8, 31–32 documentation of medical decision
Established Patient Codes, 86 making, 23–29
New Patient Codes, 85 Evaluation and Management
concurrent care, 80 services, components, 7–8
content and documentation medical record, importance of, 7
requirements vs. 1997 Documentation
cardiovascular examination, Guidelines, 78t
49t–51t 1997, 31
ear, nose and throat examination, Evaluation and Management
51t–53t services, components of,
eye examination, 53t–54t 31–32
genitourinary examination, 55t–57t documentation of coordination of
hematologic/lymphatic/ care, 77
immunologic examination, documentation of counseling, 77
57t–59t documentation of examination,
musculoskeletal examination, 43–46
59t–61t documentation of history, 32–42
neurological examination, 61t–63t documentation of medical decision
psychiatric examination, 64t–65t making, 70–77
respiratory examination, 66t–67t multispecialty examination, 49t
skin examination, 68t–70t general multisystem examination,
coordination of care, 8, 29–30, 77, 85 46t–48t
counseling, 8, 29–30, 77, 85 medical record, importance of, 31
Current Procedural Terminology vs. 1995 Documentation
(CPT), 1, 19, 41, 44, 80, 83 Guidelines 78t
Editorial Panel, 83 2021, 83
98 Index

coding for prolonged services, hematologic/lymphatic/

89–90, 90t–91t immunologic examination,
coordination of care, 85 57t–59t
counseling, 85 history, of, 8–21, 32–42
Current Procedural Terminology medical decision making, of,
changes, elements of 83–84 23–29, 70–77, 86–87, 87–88,
data classification, 87 88t
office visits, revision objectives, 83 medical record, importance of, 7
evaluation and management musculoskeletal examination,
services, 84–86 59t–61t
Established Patient Codes, 86 neurological examination, 61t–63t
history, 84–85 principles of, 3
New Patient Codes, 85 psychiatric examination, 64t–65t
time and level of service, 85–86 respiratory examination, 66t–67t
face-to-face time, 84 skin examination, 68t–70t
level of medical decision making standards, 3
table, 87–88, 88t
medical decision making, 86–87 established patient, 79
new medical decision making Evaluation and Management (E/M)
guidelines, 88 codes, 1
nonface-to-face time, 84 and facility code assignment, 1
terms and definitions, 89 importance of, 1
visit documentation, 84 service components, 7–8
documentation of history, 9t, 32, 42t service subsections, 5
guidelines, 10, 34 Evaluation and Management (E/M)
history elements, 9, 21t, 33, 33t services, 20, 23, 29, 31, 32,
history types 42, 77, 82, 83, 84
comprehensive, 9, 33 coding for prolonged services,
detailed, 9, 33 89–90
expanded problem focused, 9, 33 Current Procedural Terminology
problem focused, 8–9, 32 changes, elements of, 83–84
documentation, 1 documentation guidelines, 78t
cardiovascular examination, documentation of coordination of
49t–51t care, 29–30, 77, 85
content and documentation documentation of counseling,
requirements, 64t–71t 29–30, 77, 85
coordination of care, of, 29–30, documentation of examination,
77, 85 21–22, 43–46, 46t–70t,
counseling, of, 29–30, 77, 85 84–86
ear, nose and throat examination, documentation of history, 8–21,
51t–53t 32–42, 84–85
examination, of, 21–22, 43–46, documentation of medical decision
46t–70t, 84–86 making, 23–29, 70–77,
eye examination, 53t–54t 86–87
general multispecialty, 49t office visits, revision objectives, 83
general multisystem, 46t–48t components of, 7–8
genitourinary examination, 55t–57t contributing factors, 8, 32
guidelines, importance of, 1–2 key components, 8, 32
 Index 99

2021 Documentation Guidelines, medical decision making (MDM), 7,

84–90 23, 24t, 71t, 84, 86–87
Evaluation and Management (E/M) data review documentation
subsections, 5–6 guidelines, 25–26, 26t,
examination, 7, 43, 84 72–73, 87
body areas, 21 diagnosis/management
documentation guidelines, 22, 23t, documentation guidelines, 24,
44 25t, 71–72, 72t
exam types, 1997 guidelines, 43 factors for determining, 29t, 77t
general multispecialty, 49t level of medical decision making
cardiovascular examination, table, 87–88, 88t
49t–51t risk of complications, morbidity
ear, nose and throat examination, and/or mortality, 26–27,
51t–53t 27t–28t, 71t, 74, 75t–76t, 87
eye examination, 53t–54t treatment plan/management
genitourinary examination, 55t–57t opinion, calculation of, 23, 70
hematologic/lymphatic/ types, 23, 70–71
immunologic examination, Medicare Physician Fee Schedule
57t–59t (PFS), 83
musculoskeletal examination, morbidity, 89
59t–61t multispecialty examination, 49t
neurological examination, 61t–63t cardiovascular examination,
psychiatric examination, 64t–65t 49t–51t
respiratory examination, 66t–67t ear, nose and throat examination,
skin examination, 68t–70t 51t–53t
general multisystem, 44–45, eye examination, 53t–54t
46t–48t genitourinary examination, 55t–57t
level of service, 43 hematologic/lymphatic/
physical examination types immunologic examination,
comprehensive, 22, 45 57t–59t
detailed, 22, 45 musculoskeletal examination,
expanded problem focused, 22, 45 59t–61t
problem focused, 22, 44 neurological examination, 61t–63t
single-organ system, 45–46 psychiatric examination, 64t–65t
systems, 21–22, 43–44 respiratory examination, 66t–67t
types, 1997 guidelines, 43–44 skin examination, 68t–70t
multisystem examination, 46t–48t
family history, 9, 10, 18, 32, 40
nature of presenting problem,
Health Care Finance Administration, 8, 9, 80
2 face-to-face time, 81, 84, 85, 86
health history, 7, 31 high severity, 81
history of present illness (HPI), 7, 8, low severity, 81
9, 10, 14, 33 minimal, 80
documentation guidelines, 11–13, moderate severity, 81
35 self-limited or minor, 81, 89
elements, 11, 12t–13t, 35 unit/floor time, 81
types, 11, 13, 35 new patient, 79
100 Index

outpatient, 1, 84 documentation guidelines, 14,

36–37
past history, 7, 9, 10, 18, 33, 34, 40 purpose of, 13, 36
past, family and/or social history systems in, 13–14, 36
(PFSH), 9, 10, 18, 33, system questions and selection,
34, 40 15t–17t, 37–40
areas in, 18, 40–41 risk, 89
documentation guidelines, 19–20,
42 self-limited or minor problem, 89
documentation types for area, 18t, shared visit, 86
41t social history, 8, 9, 18, 40–41
types, 19, 41–42 split visit, 86
problem addressed, 89
prospective payment system, 1 transfer of care, 80

qualified health care professional unlisted service, 82

(QHP), 84 99499 unlisted evaluation and
management service, 82
review of systems (ROS), 9, 10, 33, 99429 unlisted preventive medicine
34, 36 service, 82