Evaluation and Management (E/M)

Medical necessity is the driver for choosing a level of service. A visit should include a chief complaint or reason for the visit. The chief complaint is a statement that describes the symptom, problem, condition, diagnosis or reason a patient seeks medical services. It should be in the patient’s own words. For workers’ compensation patients (or injured employees), medical necessity and care rendered must be directly related to the injury of record. If a patient is seeking treatment for conditions not directly related, that treatment should be billed separate from the workers’ compensation services or a separate appointment made to address those conditions.

New Patient: A patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

Established Patient: A patient who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

There are seven components of E/M services.

• History
• Exam
• Medical Decision Making
• Counseling
• Coordination of Care
• Nature of Presenting Problem
• Time

The “key” components for selecting the level of service are history, exam and medical decision making.

History

There are four types of history:

Problem Focused – Chief complaint; brief history of present illness or problem.

Expanded Problem Focused – Chief complaint; brief history of present illness; problem pertinent system review.

Detailed – Chief complaint; extended history of present illness; problem pertinent system review extended to include a review
of a limited number of additional systems; pertinent past, family and/or social history directly related to the presenting problem.

Comprehensive – Chief complaint; extended history of present illness; review of systems that are directly related to the problem(s) identified in the history of the presenting illness plus a review of all additional body systems; complete past, family and social history.

Exam

There are four types of exam:

Problem Focused – A limited examination of the affected body area or organ system.

Expanded Problem Focused – A limited examination of the affected body area or organ system and other symptomatic or related organ system.

Detailed – An extended examination of the affected body area(s) and other symptomatic or related organ system(s).

Comprehensive – A general multisystem examination or a complete examination of a single organ system.

Per Current Procedural Terminology (CPT) guidelines, body areas are:

• Head – including the face
• Neck
• Chest – including breasts and axilla
• Abdomen
• Genitalia – groin, buttocks
• Back
• Each extremity

Per CPT guidelines, the organ systems are:

• Eyes
• Ears, nose, mouth, throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric
• Hematologic/lymphatic/immunologic