Introduction to Evaluation and
Management Coding
Introduction
It is important to note that some of the rules presented may vary depending on your region. This session
aims to provide a general overview of evaluation and management coding. Please refer to your specific
payer for guidelines regarding evaluation and management coding. It is recommended that you create
an evaluation and management services guidelines policy for consistency in code selection and
application of coding practices.
Evaluation and Management (E/M) Components.
Key components
• History
• Examination
• Medical decision making
Contributing Factors
• Counseling
• Coordination of Care
• Nature of Presenting Problem
• Time
Other Criteria Based E/M Codes
1. Discharge Services
2. Critical Care Services
3. Prolonged Services Standby Services
4. Anticoagulant Management Medical Team Conferences
5. Care Plan Oversight Services
6. Preventive Medicine
7. Preventive Medicine, Counseling
8. Non-Face-to-Face Services
9. Delivery/Birthing Room Attendance And Resuscitation
10. Inpatient Neonatal Intensive Care
Services and Neonatal Critical Care Services
11. Care Management Services Transitional Care Management
12. Advance Care Planning
, Components of CPT Code
There are seven components to a potential CPT code. Some potential CPT codes are not based on key
components but rather on other characteristics such as discharge services which have a primary division
of time. The other four components are contributing factors, which contribute to an evaluation and
managerial service being performed. When applicable, a provider can use the other four components in
addition to the key components to contribute to a possible CPT code.
Guidelines for Evaluation and Management Services
It is important to review the guidelines in front of the evaluation and management services, and all of
the guidelines subsection notes that appear throughout the evaluation and management service. Using
your index, you can use the type of service, the place of service or patient status to locate the range of
codes for the encounter that you are going to code today. The one rule to remember is whether the
patient has received any professional services from the physician or qualified health care professional
within the past three years. If the answer is yes, the next question is if it is the exact same specialty.
Chief Complaint
The chief complaint is the reason why the patient is seeing the provider today. The history of present
illness is a chronologic code description of the development of the patient’s illness from the first sign
and/or symptom to present. The provider’s ultimate responsibility is to ensure that the chief complaint
can be stated or can be easily inferred. It is not acceptable to use the word ‘’followup’’ for the chief
complaint.
The history of present Illness can be brief or extended. Brief means that the provider has described 13
HPI elements, while extended means that the provider has described four or more elements of the HPI.
The 1997 guidelines state that the HPI can also be quantified for situations where the patient isn’t
necessarily sick, but is coming in to follow up on their chronic condition. We have the duration, quality,
location, and associated signs and symptoms. The review of systems helps the provider define the
problem, clarify any differential diagnosis, identify any needed testing that the provider has to request,
and it can also serve as baseline data on other systems that may be affected by any possible
management options.
CPT defines the review of systems as an inventory of body systems obtained through a series of
questions seeking to identify signs and/or symptoms that the patient may be experiencing or has
experienced. Review of systems and HPI must be counted individually. If the provider documents one
system that was reviewed, that’s known as a problem pertinent review of systems. If the provider
reviews 29 systems, that’s known as an extended review. The last part of the history is past, social,
family history.
Management Coding
Introduction
It is important to note that some of the rules presented may vary depending on your region. This session
aims to provide a general overview of evaluation and management coding. Please refer to your specific
payer for guidelines regarding evaluation and management coding. It is recommended that you create
an evaluation and management services guidelines policy for consistency in code selection and
application of coding practices.
Evaluation and Management (E/M) Components.
Key components
• History
• Examination
• Medical decision making
Contributing Factors
• Counseling
• Coordination of Care
• Nature of Presenting Problem
• Time
Other Criteria Based E/M Codes
1. Discharge Services
2. Critical Care Services
3. Prolonged Services Standby Services
4. Anticoagulant Management Medical Team Conferences
5. Care Plan Oversight Services
6. Preventive Medicine
7. Preventive Medicine, Counseling
8. Non-Face-to-Face Services
9. Delivery/Birthing Room Attendance And Resuscitation
10. Inpatient Neonatal Intensive Care
Services and Neonatal Critical Care Services
11. Care Management Services Transitional Care Management
12. Advance Care Planning
, Components of CPT Code
There are seven components to a potential CPT code. Some potential CPT codes are not based on key
components but rather on other characteristics such as discharge services which have a primary division
of time. The other four components are contributing factors, which contribute to an evaluation and
managerial service being performed. When applicable, a provider can use the other four components in
addition to the key components to contribute to a possible CPT code.
Guidelines for Evaluation and Management Services
It is important to review the guidelines in front of the evaluation and management services, and all of
the guidelines subsection notes that appear throughout the evaluation and management service. Using
your index, you can use the type of service, the place of service or patient status to locate the range of
codes for the encounter that you are going to code today. The one rule to remember is whether the
patient has received any professional services from the physician or qualified health care professional
within the past three years. If the answer is yes, the next question is if it is the exact same specialty.
Chief Complaint
The chief complaint is the reason why the patient is seeing the provider today. The history of present
illness is a chronologic code description of the development of the patient’s illness from the first sign
and/or symptom to present. The provider’s ultimate responsibility is to ensure that the chief complaint
can be stated or can be easily inferred. It is not acceptable to use the word ‘’followup’’ for the chief
complaint.
The history of present Illness can be brief or extended. Brief means that the provider has described 13
HPI elements, while extended means that the provider has described four or more elements of the HPI.
The 1997 guidelines state that the HPI can also be quantified for situations where the patient isn’t
necessarily sick, but is coming in to follow up on their chronic condition. We have the duration, quality,
location, and associated signs and symptoms. The review of systems helps the provider define the
problem, clarify any differential diagnosis, identify any needed testing that the provider has to request,
and it can also serve as baseline data on other systems that may be affected by any possible
management options.
CPT defines the review of systems as an inventory of body systems obtained through a series of
questions seeking to identify signs and/or symptoms that the patient may be experiencing or has
experienced. Review of systems and HPI must be counted individually. If the provider documents one
system that was reviewed, that’s known as a problem pertinent review of systems. If the provider
reviews 29 systems, that’s known as an extended review. The last part of the history is past, social,
family history.
