Evaluation and Management (E/M) Patient Examples

Office, Established Patient

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IMPORTANT
The sample progress notes below meet criteria for the specified E/M code, but do not necessarily meet criteria for the multiple other purposes (e.g., clinical, legal)
of documentation. For illustration, the documentation meets requirements specified by the codes for the exact levels of each of the 3 key components. In practice,
criteria for these codes may be met by documenting only 2 of 3 of the key components at or above the level required by the code.
SERVICES SHOULD ALWAYS BE MEDICALLY NECESSARY.

Office visit for a 9-year-old male, established patient, with ADHD. Mild Office visit for a 27-year-old female, established patient, with stable
99213 symptoms and minimal medication side effects. depression and anxiety. Intermittent moderate stress.
CC 9-year-old male seen for follow up visit for ADHD. Visit attended by patient and 27-year-old female seen for follow up visit for depression and anxiety. Visit
mother; history obtained from both. attended by patient.

Expanded Problem
HISTORY:
HPI Grades are good (associated signs and symptoms) but patient appears distracted Difficulty at work but coping has been good. Minimal (severity) situational sadness
HISTORY

Focused
(quality) in class (context). Lunch appetite poor but eating well at other meals. (quality) and anxiety when stressed (context).
HPI scoring: 3 elements = Brief HPI scoring: 3 elements = Brief
PFSH N/A N/A
ROS Psychiatric: denies depression, anxiety, sleep problems Psychiatric: no sadness, anxiety, irritability
ROS scoring: 1 system = Problem-pertinent ROS scoring: 1 system = Problem-pertinent

Const Appearance: appropriate dress, comes to office easily Appearance: appropriate dress, appears stated age

Exp. Problem
MS N/A N/A

Focused

EXAM:
EXAM

Psych Speech: normal rate and tone; Thought content: no SI/HI or psychotic symptoms; Speech: normal rate and tone; Thought content: no SI/HI or psychotic symptoms;
Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and
appropriate appropriate; Judgment and insight: good
Examination scoring: 6 elements = Expanded problem-focused Examination scoring: 7 elements = Expanded problem-focused

Problem 1: ADHD Problem 1: Depression

Comment: Relatively stable; mild symptoms Comment: Stable

MEDICAL DECISION
MEDICAL DECISION

Plan: Renew stimulant script and increase dose; Plan: Renew SSRI script at the same dose;
Return visit in 2 months Return visit in 3 months

Low Complexity
MAKING:
MAKING

Problem 2: Anxiety
Comment: Stable
Plan: Same dose of SSRI

Prob Problem scoring: 1 established problem, stable (1); total of 1 = Minimal Problem scoring: 2 established problems, stable (1 for each = 2); total of 2 = Limited

Data Data scoring: Obtain history from someone other than patient (2); total of 2 = Limited Data scoring: None = Minimal

Risk Risk scoring: Chronic illness with mild exacerbation, progression, or side effects; and Risk scoring: Two stable chronic illnesses; and Prescription drug management = Moderate
Prescription drug management = Moderate
 Evaluation and Management (E/M) Patient Examples

Office visit for a 13-year-old male, established patient, with depression, Office visit for a 70-year-old male, established patient, with stable depression
99214 anxiety, and anger outbursts. and recent mild forgetfulness.
CC 13-year-old male seen for follow up visit for mood and behavior problems. Visit 70-year-old male seen for follow up visit for depression. Visit attended by patient and
attended by patient and father; history obtained from both. daughter; history obtained from both.

HPI Patient and father report increasing (timing), moderate (severity) sadness (quality) Patient and daughter report increasing distress related to finding that he has repeatedly
that seems to be present only at home (context) and tends to be associated with lost small objects (e.g., keys, bills, items of clothing) over the past 2-3 months (duration).
yelling and punching the walls (associated signs and symptoms) at greater frequency, Patient notices intermittent (timing), mild (severity) forgetfulness (quality) of people’s

HISTORY:
HISTORY

at least once per week when patient frustrated. Anxiety has been improving and names and what he is about to say in a conversation. There are no particular stressors

Detailed
intermittent, with no evident trigger (modifying factors). (modifying factors) and little sadness (associated signs and symptoms).
HPI scoring: 6 elements = Extended HPI scoring: 6 elements = Extended

PFSH Attending 8th grade without problem; fair grades Less attention to hobbies
PFSH scoring: 1 element: social = Pertinent PFSH scoring: 1 element: social = Pertinent

ROS Psychiatric: no problems with sleep or attention; Psychiatric: no problems with sleep or anger;
Neurological: no headaches Neurological: no headaches, dizziness, or weakness
ROS scoring: 2 systems = Extended ROS scoring: 2 systems = Extended
Const Appearance: appropriate dress, appears stated age Appearance: appropriate dress, appears stated age
MS N/A Muscle strength and tone: normal

Detailed
EXAM:
Psych Speech: normal rate and tone; Thought process: logical; Associations: intact; Speech: normal rate and tone; Thought process: logical; Associations: intact; Thought
EXAM

Thought content: no SI/HI or psychotic symptoms; Orientation: x 3; Attention content: no SI/HI or psychotic symptoms; Orientation: x 3; Attention and concentration:
and concentration: good; Mood and affect: euthymic and full and appropriate ; unable to focus on serial 7s; Mood and affect: euthymic and full and appropriate;
Judgment and insight: good Recent and remote memory: mild struggle with telling history and remembered 1/3
objects
Examination scoring: 9 elements = Detailed Examination scoring: 10 elements = Detailed
Problem 1: Depression Problem 1: Depression
Comment: Worsening; appears associated with lack of structure Comment: Stable; few symptoms
Plan: Increase dose of SSRI; write script; CBT therapist; Plan: Continue same dose of SSRI; write script

MEDICAL DECISION MAKING:

MEDICAL DECISION MAKING

Return visit in 2 weeks Return visit in 1 month

Problem 2: Anxiety Problem 2: Forgetfulness
Comment: Improving Comment: New; mildly impaired attention and memory

Moderate Complexity
Plan: Patient to work with therapist on identifying context Plan: Brain MRI; consider referral to a neurologist if persists

Problem 3: Anger outbursts

Comment: Worsening; related to depression but may represent
mood dysregulation
Plan: Call therapist to obtain additional history; consider a mood
stabilizing medication if no improvement in 1-2 months

Prob Problem scoring: 2 established problems, worsening (2 for each problem = 4); Problem scoring: 1 established problem, stable (1);
1 established problem, improving (1); total of 5 = Extensive 1 new problem with additional workup (4); total of 5 = Extensive
Data Data scoring: Obtain history from other (2); Decision to obtain history from other (1); Data scoring: Order of test in the radiology section of CPT (1);
total of 3 = Multiple Obtain history from other (2); total of 3 = Multiple
Risk Risk scoring: One or more chronic illnesses with mild exacerbation, progression; and Risk scoring: Undiagnosed new problem with uncertain prognosis; and
Prescription drug management = Moderate Prescription drug management = Moderate
 Evaluation and Management (E/M) Patient Examples

Office visit for an established adolescent patient with history of bipolar Office visit for a 25-year-old male, established patient with a history of
99215 disorder treated with lithium; seen on urgent basis at family's request schizophrenia, who has been seen bi-monthly but is complaining of auditory
because of severe depressive symptoms. hallucinations.
CC 17-year-old male seen for urgent visit for depression. Visit attended by patient and 25-year-old male seen for follow up visit for schizophrenia. Visit attended by patient.
parents; history obtained from all 3.
HPI Patient doing well until 2 days ago (timing) when, for no apparent reason (context), The patient reports doing well until 1 week ago (duration) when he stayed up all night
he refused to leave his bed and appeared extremely (severity) and continuously to finish a term paper (context). He has slept poorly (severity) since (timing) and, 2 days
depressed (quality); he is sleeping more and eating little (associated signs and ago, began hearing fairly continuous voices (quality) telling him that people plan to

Comprehensive
HISTORY:
symptoms). shoot him. Attention and organization were good up until this past week (associated
HISTORY

signs and symptoms).

HPI scoring: 5 elements = Extended HPI scoring: 6 elements = Extended
PFSH Stopped attending school; family history of suicide is noted from patient’s initial Doing well in third year of graduate school. Chart notes no family psychiatric history.
evaluation
PFSH scoring: Family and social (2 elements) = Complete PFSH scoring: Family and social (2 elements) =Complete
ROS Psychiatric: no problems with anxiety or anger; Neurological: no headaches; All Psychiatric: denies symptoms of depression or mania; Neurological: no headaches; All
other systems reviewed and are negative. other systems reviewed and are negative.
ROS scoring: All systems = Complete ROS scoring: All systems = Complete
Const VS: BP (sitting) 120/70, P 90 and regular, R 20; Appearance: appropriate dress, VS: BP (sitting) 115/70, P 86 and regular, Ht 5’10”, Wt 180 lbs; Appearance:
appears stated age appropriate dress, appears stated age

EXAMINATION:
EXAMINATION

MS Gait and station: normal Gait and station: normal

Comprehensive
Psych Speech: sparse and slow; Thought process: logical; Associations: intact; Thought Speech: normal rate and tone; Thought process: logical; Associations: intact; Thought
content: hopelessness, thinks of suicide, no HI or psychotic symptoms; content: auditory hallucinations and paranoid ideation, no SI/HI; Orientation: x 3;
Orientation: x 3; Attention and concentration: impaired; Mood and affect: Attention and concentration: impaired; Mood and affect: euthymic and full and
depressed and constricted; Judgment and insight: poor; Fund of knowledge: good; appropriate; Judgment and insight: good; Fund of knowledge: good; Recent and
Recent and remote memory: good; Language: able to repeat phrases remote memory: good; Language: able to repeat phrases
Examination scoring: All elements of constitutional and psychiatric and 1 element of Examination scoring: All elements of constitutional and psychiatric and 1 element of
musculoskeletal = Comprehensive musculoskeletal = Comprehensive

Problem 1: Bipolar disorder Problem 1: Psychosis

MEDICAL DECISION MAKING:

Comment: Major relapse Comment: Major relapse
MEDICAL DECISION MAKING

Plan: Continue current dose of Lithium for the moment Plan: Increase dose of antipsychotic; write script; hold off on hospital
admission as patient historically very adherent; return for visit in 1 day
Problem 2: Suicidality Problem 2: Insomnia

High Complexity
Comment: New Comment: Sleep deprivation may have triggered the psychosis relapse
Plan: Refer to hospital; confer with hospitalist once patient is admitted Plan: Change to a more powerful hypnotic; write script
Problem 3: ADHD
Comment: Appears stable
Plan: Continue same dose of non-stimulant medication
Prob Problem scoring: 1 established problem, worsening (2); 1 new problem (3); Problem scoring: 1 established problem, stable (1); 2 established problems, worsening (2 for
total of 5 = Extensive each problem = 4); total of 5 = Extensive
Data Data scoring: Obtain history from other (2); total of 2 = Limited Data scoring: None = Minimal

Risk Risk scoring: Chronic illness with severe exacerbation; and Risk scoring: Chronic illness with severe exacerbation = High
Illness that poses a threat to life = High