Chapter 17: E/M Notes
Evaluation and Management (E/M) Services
Introduction and Objectives
E/M services are located at the front of the CPT code book and are frequently reported by providers across various medical specialties.
Proper E/M service reporting requires a methodical approach to documentation and code selection.
Objectives include:
Defining E/M services.
Summarizing CPT E/M service guidelines.
Reviewing common terms (new patient, established patient, transfer of care, etc.).
Explaining medical decision making (MDM) elements.
Differentiating between E/M service categories (office visits, hospital visits, consultations, etc.).
Providing guidance on selecting appropriate E/M service levels based on MDM or time.
Discussing the importance of time in E/M service leveling.
Highlighting differences between CPT and CMS treatment of E/M services.
Establishing the importance of ICD-10-CM code assignment to support E/M services.
Demonstrating concepts through examples.
E/M Services Defined
E/M codes (99202-99499) cover provider services, including evaluation of a patient's condition(s) and determining required care management.
Services based solely on time may also be defined as E/M services.
E/M services can range from simple to very complex, based on:
Severity of the patient's problem.
Difficulty in determining a diagnosis.
Number of possible treatment options.
E/M codes are categorized by:
Location of service (office visits, ED visits, nursing facility care, etc.).
Type of service (consultations, critical care).
Patient age (neonatal intensive care).
Patient status (new vs. established).
Levels of E/M codes are often referred to as level 1, level 2, level 3, etc., based on the last number of the code.
Diagnostic or therapeutic procedures are not included in E/M services and may be reported separately.
Many diagnostic and therapeutic procedures include an inherent E/M component.
If a diagnostic or therapeutic procedure is performed or ordered during the same-day E/M service, both may be reported separately.
If the diagnostic or therapeutic procedure was scheduled at a previous encounter, a separate E/M service may not be reported unless the patient has a new problem or a significant exacerbation requiring a separate E/M service.
Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health professional on the same day of the procedure or other service) applies in these cases.
CPT® E/M Services Guidelines
CPT provides detailed guidelines for E/M service reporting in the E/M Services Guidelines, with additional instructions throughout the CPT E/M section.
Coders and providers should carefully read and regularly review these guidelines and instructions.
New vs. Established Patient
E/M service categories differentiate between new and established patients; evaluating a new patient generally requires more work than evaluating an established one.
A patient is considered new if they have not received any face-to-face professional services from the physician or other qualified healthcare professional, or a physician or other qualified healthcare professional of the exact same specialty/subspecialty within the group practice, within the last three years (36 months), known as the "three-year rule."
If a patient is seen by another member of the group within the past three years but that provider is of a different specialty/subspecialty, the patient may still be new.
When a patient is seen by a nurse practitioner or physician assistant, that provider is considered to have the same specialty and subspecialty of the provider they are working with.
When a physician or other qualified health care professional is on call or covering for another physician or other qualified healthcare professional, the patient's encounter will be classified as it would have been by the physician or other healthcare professional who is not available.
The location of the service does not determine new vs. established patient status.
If a physician has provided services face-to-face with a patient in the hospital and sees the same patient in his or her office within three years, the patient is established.
Initial and Subsequent Services
Initial versus subsequent is determined based on a professional service (face-to-face encounter) rendered by a physician or other qualified healthcare professional who may report an evaluation and management service.
An initial visit is defined as when a patient has not received any professional services from the physician or other qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice during the inpatient, observation, or nursing facility admission and stay. A stay includes the transition from observation to inpatient or skilled nursing facility to nursing facility.
If a physician or other qualified healthcare professional is on call or covering for another physician or other qualified healthcare professional, the patient's encounter will be classified as it would have been by the physician or other healthcare professional who is not available.
E/M Service Categories
The first step in selecting an E/M service code is to determine the appropriate E/M category for the service provided.
Office or Other Outpatient Services
This category is divided into subcategories for new and established patients and includes visits performed in the provider's office, outpatient hospital, or other ambulatory facility.
Guidelines for leveling Office or Other Outpatient Services are listed in the E/M Guidelines in the CPT code book.
Telemedicine Services
Telemedicine services mimic an office visit using Synchronous Audio-Video or Synchronous Audio-Only Methods.
The level of visit is based on medical decision making or the total time spent by the provider on the date of the encounter and whether the patient is new or established.
Audio-only services must exceed a minimum of 10 minutes to be reported.
For a brief synchronous communication with an established patient that is not related to an E/M service in the prior seven days or leading to an E/M in the next 24 hours, 98016 is reportable.
Time less than five minutes is not reportable.
Hospital Inpatient or Observation Care Services
This category includes four types of service: Initial Hospital Inpatient or Observation Care Services, Subsequent Hospital Inpatient or Observation Care, Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services), and Hospital Inpatient or Observation Discharge Services.
The physician admitting the patient to observation status reports the initial inpatient or observation care.
Medicare allows the use of Initial Hospital Care codes in place of Inpatient Consultation codes.
If the provider performs an evaluation and management service in another location and then performs an evaluation and management service in the inpatient or observation setting, both services may be separately reported. Modifier 25 is appended to the other evaluation and management code.
Medicare does not allow for the reporting of two evaluation and management services. Any services performed on the same date of service, when related to the admission, should be included in the Initial Hospital or Observation Care code and not reported separately. This includes office visits, observation visits, and nursing facility visits if provided by the same provider on the same date of service.
Subsequent Hospital or Observation Care codes are used to report the subsequent visits to the patient while the patient is in the hospital. These codes include the provider reviewing the medical record, diagnostic test results, and changes in the patient's status since the last assessment.
Observation or Inpatient Care Services (including Admission and Discharge Services) codes should be used to report an admission and discharge on the same date of service.
Hospital Inpatient and Observation Discharge Day Management Services codes report the total time the provider spent on the date of discharge. Discharge services include the final examination, a discussion of the stay, continuing care instructions, discharge paperwork, prescriptions, and referral forms. time is not continuous. Visits to the patient on the date of discharge by providers who are not the attending physician (or other qualified healthcare professional) should be reported using Subsequent Hospital and Observation Care codes (99231-99233).
Consultations
Consultation codes are divided into two subcategories based on the location of the consult: Office or Other Outpatient Consultations and Inpatient Consultations.
According to CPT, a consultation has the following components:
A physician (or other appropriate source) requests another physician (or appropriate source) to evaluate a patient's specific problem or condition and render an opinion. The request can be written or verbal; if verbal, the request must be documented in the patient's medical record.
The opinion or advice of the consultant can result in giving recommendations for the patient's condition, or in the consultant providing ongoing management of the patient's condition.
The consultant's written report back to the requesting physician (or other appropriate source).
A consultation differs from a referral. A referral occurs when a patient is sent to another provider for care of a specific problem or condition. The requesting provider is not expecting to receive recommendations back from the referring provider.
If another provider requests an opinion or advice on the same condition, or a new condition, for the same patient in the outpatient setting, the consulting provider can again report a consultation code. If an additional consultation is requested in the inpatient or observation setting, the consulting provider reports a subsequent hospital care code.
According to CPT guidelines, only one consultation can be reported by a consultant per admission.
When transfer of care has been established, the provider accepting the patient's care bills subsequent visits with the appropriate established patient visit codes based on the location; Office or Other Outpatient Established Patient Visit (99211-99215), Home or Residence Services (99347-99350), Subsequent Hospital or Observation Care Services (99231-99233), or Subsequent Nursing Facility (99307-99310).
Consultations requested by a patient or family member should be reported using the appropriate codes from categories other than consultation; Office or Other Outpatient Visits or Home or Residence Service. When a consultation is mandated by a third-party payer, or by government, legislative, or regulatory requirement, append modifier 32 Mandated services to the consultation code.
Reporting Consultations for Medicare
As is true with all services, payers may have their own policy regarding the use of consultation codes. Medicare no longer pays s for consultation codes (except telehealth consultations) and has provided guidelines on how consultation codes should be reported.
Medicare requires consultations services be billed with the most appropriate (non-consultation) E/M code for that service.
Outpatient consultations should be reported by selecting the appropriate level code from the Office or Other Outpatient Services (99202-99215). Report inpatient or observation consultations using an Initial Hospital or Observation Care code (99221-99223) for the initial evaluation and a Subsequent Hospital or Observation Care code (99231-99233) for the subsequent visits. The provider who admitted the patient as a hospital inpatient (whether that provider is the "consultant" or another provider), should append modifier A1 Principal physician of record to indicate that he or she is the admitting physician, and to distinguish that physician from others who may provide inpatient services.
Other payers may allow you to continue reporting consultation codes. Check with individual payers for guidelines.
Emergency Department Services
An emergency department (ED) is a section of a hospital organized and designated to treat unscheduled patient visits for immediate medical attention. Emergency departments must be open 24 hours a day, seven days a week.
A patient may receive critical care treatment in an emergency department. Report critical care codes when this happens.
Another service found in this category is the physician or other qualified healthcare professional direction of emergency medical systems (EMS) emergency care, advanced life support (99288). This code reports the services of a provider, located in a facility's emergency department or critical care department, who is in two-way communication with emergency services personnel. The provider directs the personal in performing life-saving procedures.
Critical Care Services
Critical Care Services codes are used to report the direct delivery, by a physician or other qualified healthcare professional, of medical care to a critically injured or critically ill patient. According to CPT, "a critical illness or injury acutely impairs one or more vital organ systems, such that there is a high probability of imminent or life-threatening deterioration in the patient's condition."
Critical care is a condition, not a location. A patient does not have to be in an intensive care unit (ICU) or other designated area to meet the requirements of critical care; nor do all patients in an ICU or other designated unit automatically qualify for critical care.
Only patients who meet the definition of critically ill or critically injured may qualify for critical care services.
Critical care bundles a number of services, such as cardiac output measurements , that typically may be required for critically ill or critically injured patients. A complete list of services bundled with critical care may be found in the critical care portion of the CPT code book.
Any procedures performed by the provider not included in the procedures bundled in critical care can be separately reported (example, 31500 Intubation, endotracheal, emergency procedure). The provider needs to document that the separately reportable procedures are not included in the critical care time. If this is not documented, time needs to be deducted from the critical care time to report those services.
Critical Care Services codes are reported based on time. The time includes all the time the provider spent devoted to, and directly available to, that patient. The provider cannot work on any other patient during this time; however, the time is not required to be continuous and the provider is not required to be in the same room as the patient. The provider can only report time spent on the same unit or floor as the patient. All time spent on managing the patient's condition while on the same floor or unit as the patient is totaled throughout the day and reported with 99291 and 99292. When the total time of critical care is less than 30 minutes, critical care codes are not reported.
When the total time is between 30 and 74 minutes, report code 99291. Each additional 30 minutes, or part thereof, is reported with a unit of 99292.
Example: Physician provides 125 minutes of critical care to a patient. These services would be reported as 99291, 99292 x 2:
99291 for the first 74 minutes;
99292 for the next 30 minutes (minutes 75-104); and
99292 for the remaining 21 minutes.
For younger patients, specific code ranges may apply when reporting critical care:
Neonates (28 days of age or younger)-Inpatient critical care services are reported with neonatal critical care codes 99468 and 99469.
Infants 29 days through 24 months of age-Inpatient critical care services are reported with pediatric critical care codes 99471-99472.
Inpatient Neonatal and Pediatric Critical Care for 2 years through 5 years of age is coded with 99475-99476.
Critical Care for children 6 years of age and older are coded with 99291 and 99292.
Nursing Facility Services
Nursing Facility Services are subcategorized into Initial Nursing Facility Care, Subsequent Nursing Facility Care, Nursing Facility Discharge Services, and Other Nursing Facility Services.
E/M services provided to patients in a nursing facility, psychiatric residential treatment services, or immediate care facility for individuals with intellectual disabilities are reported using codes from this category.
When selecting a level of medical decision making (MDM) for nursing facility services, the number and complexity of problems addressed at the encounter is considered. For this determination, a high-level MDM-type specific to initial nursing facility care by the principal physician or other qualified health care professional is recognized.
Multiple morbidities requiring intensive management: A set of conditions, syndromes, or functional impairments that are likely to require frequent medication changes or other treatment changes and/or re-evaluations. The patient is at significant risk of worsening medical (including behavioral) status and risk for (re)admission to a hospital.
For Medicare, the initial visit can be reported by more than one provider, but the provider of record for an admission to the nursing home should append modifier A1 to indicate he or she is the primary provider of record.
Nursing facility discharge codes report the services provided by a provider to discharge the patient. The codes are reported by time, which includes all time spent on the patient for the date of discharge.
Home or Residence Services
E/M services provided to a patient in a private residence, temporary lodging or short-term accommodations are reported from this category.
These codes are also used for assisted living facility, group home, custodial care facility, or residential substance abuse treatment facility. The codes distinguish between new and established patients.
Prolonged Services
The following categories of services in this section are:
Prolonged Service on Date Other Than the Face-to-Face Evaluation and Management Service Without Direct Patient Contact.
Prolonged Clinical Staff Services With Physician or Other Qualified health Care Professional Supervision
Prolonged Service With or Without Direct Patient Contact on the Date of an Evaluation and Management Service
Prolonged services are reported based on:
The date of the prolonged service (whether it was the same date as the associated E/M service or not)
Who provided the prolonged service (the physician or clinical staff)
The patient status (outpatient, inpatient, or observation)
The guidelines in this section are extensive and identify the amount of time that must be included before the codes are reportable and what type of activities are included in the time reported. For Medicare beneficiaries, G codes from the HCPCS Level II code book are reported for prolonged services.
Case Management Services
The Case Management Services category includes Anticoagulant Management and Medical Team Conference.
Medical Team Conference codes report meeting or conference time (face-to-face) of at least three qualified healthcare professionals, with or without the presence of the patient or patient's family member. The healthcare professionals should be of different specialties, and all should be involved directly in the patient's care. The code is selected based on whether the patient or patient's family is present. If the patient or patient's family is not present, the code is selected based on the type of provider (physician or nonphysician qualified healthcare professional).
Care Plan Oversight Services
When the care of a patient involves complex and multidisciplinary care modalities, physician (or other qualified healthcare professional) supervision is required to monitor the patient's progress and adjust the care plan, as necessary.
These services are reported with the codes from the Care Plan Oversight Services category. The codes are selected based on the location of the patient, and the amount of time spent within a 30-day period to oversee the patient's care.
Preventive Medicine Services
Preventive Medicine Services, also referred to as "well visits," describe E/M services provided to a patient without a sign, symptom, condition, or illness. The comprehensive exam as described here is an age-appropriate examination of the patient, and not the same as the comprehensive exam referred to in other E/M code categories. The preventive medicine codes are determined based on the age of the patient, and whether the patient is new or established.
During preventive medicine exams, a provider may discover an abnormality, or address a condition already in existence. If the abnormality or condition requires the provider to perform a significant amount of work, above normally is performed for a preventive service, the additional work can be reported with a separate E/M service code. The additional E/M code is reported with modifier 25 appended. When determining whether a problem required a significant amount of work, separate the documentation into two distinct separate notes, one to support each service.
The reporting and payment of preventive services and additional E/M codes will depend largely on payer policy. Effective Jan. 1, 2011, Medicare pays for preventive medicine visits. Many commercial policies do not include preventive visits as a benefit.
The Preventive Medicine Services category includes the subcategories Counseling Risk Factor Reduction and Behavior Change Intervention services.
Preventive Medicine, Individual Counseling codes are for services provided to patients to prevent a risky behavior from developing or to prevent injury from happening. The counseling occurs to address issues such as drug abuse, family problems, diet, and exercise, etc. These services may not be reported in addition to preventive medicine visits (99381-99397). Codes selection is based on the face-to-face time spent with the patient, and according to whether the counseling is provided to an individual or in a group setting.
Behavior Change Interventions, individual services are provided to patients who have already developed the risky behavior. Smoking cessation (quitting smoking) counseling, and alcohol and substance abuse counseling, are found in the behavior change intervention codes. The codes are selected based on the substance and the amount of time spent with the patient.
Non-Face-to-Face Services
Non-Face-to-Face Services are becoming increasingly popular with the advancement of technology.
Online Medical Evaluation codes have similar guidelines. Online evaluations must be permanently stored. Online communications with the patient involving E/M services provided by the provider within seven days prior to the communication are not reported separately.
Codes are also available to report interprofessional consultative discussion and review provided via telephone/internet assessment by a consulting physician. Code selection is based on the amount of time for medical consultative discussion and review.
Special Evaluation and Management Services
Obtaining basic life or disability insurance requires a medical evaluation, and that a provider complete some forms on the patient's behalf. In the Basic Life and/or Disability Evaluation Services subcategory, codes exist to report these services. The code is selected based on the type of benefit being sought (basic life or disability).
Newborn Care Services
After the delivery of a newborn, the newborn is evaluated by a pediatrician or other qualified practitioner. Codes in this category are reported based on the location of the delivery and episode of care (initial or subsequent).
Additional critical services may be provided to the newborn immediately after delivery. These services include attendance at the delivery and stabilization of the newborn (99464) and the resuscitation, provision of positive pressure ventilation, and/or chest compressions (99465).
Inpatient Neonatal Intensive Care Services and Pediatric Neonatal Critical Care Services
CPT includes two age-specific (24 months of age or less) codes for pediatric critical care patient transport (99466, 99467). These services require direct, face-to-face contact. Physician (or other qualified healthcare professional) direction of emergency care using two-way communication does not qualify as pediatric critical care transport and should be reported 99288 Physician or other qualified healthcare professional direction of emergency medical systems (EMS) emergency care, advanced life support.
Codes 99466-99467 and 99485-99486 are time-dependent. Reporting time begins when the provider assumes primary responsibility of the patient at the referring facility and ends when the receiving facility accepts responsibility for the patient, according to CPT guidelines.
Pediatric critical care codes apply only for direct, physician (or other qualified healthcare professional) delivered care to the critically ill or critically injured patient, age 28 days or younger (99468-99469), age 29 days up to 24 months (99471-99472), or 2-5 years of age (99475-99476). CPT defines a critical illness or injury for all patients, regardless of age, as impairment of one or more vital organ systems, "such that there is a high probability of imminent or life-threatening deterioration the patient's condition."
Pediatric critical care codes 99471-99476 include all the same services as adult critical care, plus additional services (such as ventilator management and lumbar puncture) as listed in the Inpatient Neonatal and Pediatric Critical Care services guidelines. Always check your CPT code book prior to coding for additional services with critical care, to be sure those additional services are separately reportable.
Only one provider may report pediatric critical care for the same patient, for any calendar day. When providers from different groups provide same-day services at two separate facilities, the referring provider reports critical care and the receiving provider reports the admission service. If two separate providers from different groups provide critical care on different days, each provider may report the appropriate pediatric critical care code for his or her respective service.
Codes 99477-99480 describe initial (99477) and subsequent (99478-99480) intensive care for a child. Intensive care is not the same as critical care. CPT clarifies that children requiring intensive care are not critically ill, but require "intensive observation, frequent interventions, and other intensive care services."
The initial care code applies only to neonates, age 28 days or less. CPT provides parenthetical notes to direct coding for services provided to children who do not meet the requirements of 99477. Subsequent care is reported per day and depends on the infant's body weight: 1500 grams or less (99478), 1500-2500 grams (99479), or 2501-5000 grams (99480).
Care Management Services
Patients with one or more chronic illnesses may require coordination of complex chronic care. The patient's condition must be expected to last at least 12 months or until the death of the patient to report codes 99487-99490. When chronic care services are performed by clinical staff directed by a physician or other qualified healthcare professional, code 99490 is reported. Services less than 20 minutes per month are not reported. When the provider personally performs the chronic care services, code 99491 may be reported for the first 30 minutes s spent during the calendar month. 99439 is reported for each additional 30 minutes during the same calendar month. When the care is more complex, requiring establishment or substantial revisions of a comprehensive care plan requiring medical decision making of moderate or high complexity, and requires clinical staff care management services for at least 60 minutes, codes 99487-99489 are reported.
The provider or other qualified healthcare professional overseeing the care plan and coordination reports the code based on time and whether the patient is seen within the reporting period or not. The codes are reported based on the total time within a calendar month. Patients who receive this type of service live at home or in a domiciliary, rest home, or assisted living facility.
According to CPT coding guidelines, "The physician or other qualified health care professional provides or oversees the management and/or coordination of care management services, which include establishing, implementing, revising, or monitoring the care plan, coordinating the care of other professionals and agencies, and educating the patient or caregiver about the patient's condition, care plan, and prognosis."
Complex Chronic Care Coordination
Patients with one or more chronic illnesses may require coordination of complex chronic care. The patient's condition must be expected to last at least 12 months or until the death of the patient to report codes 99487-99489. The provider overseeing the care plan and coordination reports the code based on time and whether the patient is seen within the reporting period or not. The time reported is based on the provider's time, other qualified healthcare professionals and clinical staff. The codes in this category can only be reported once in a calendar month. Patients who receive this type of service live at home or in a domiciliary, rest home, or assisted living facility. Review the CPT guidelines and parenthetical note for services that are included or not reported in addition to complex care management.
Transitional Care Management Services
A patient discharged from an inpatient setting (acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility to the patient's community setting (home, domiciliary, rest home, or assisted living) may require transitional care to prevent repeat admissions. The codes in this subsection can only be reported once in a 30-day period. The codes (99495-99496) are selected based on the level of medical decision making (moderate or high) and when the first face-to-face encounter occurs after discharge (within 14 calendar days after discharge or seven calendar days after discharge).
Other Evaluation and Management Services
The only code in this section is unlisted E/M service code 99499. This code would be reported only if no other available E/M code describes the service provided. When reporting an unlisted service or procedure code, documentation must substantiate the nature of the service. Whenever possible, avoid reporting such an unlisted code.
Split or Shared Services
In the context of team-based care, providers and QHPs can work together to provide a single E/M service for a patient. The guidelines for split or shared visits determine which professional can report the service. If a substantial part of the encounter is performed by a doctor or other QHP, they can report the service. When the code selection depends on the total time spent on the date of the encounter, the professional who contributes the most face-to-face or non-face-to-face time to the service reports it. For E/M services, a substantive part of the medical decision making (MDM) requires the doctor or other QHP to create or approve the management plan, considering the number and complexity of problems addressed at the encounter. They must also take responsibility for the plan and its inherent risk of complications and/or patient management morbidity or mortality. This means that a doctor or other QHP has fulfilled two of the three elements used in code level selection based on MDM. If the amount and/or complexity of data to be reviewed and analyzed is used to determine the reported code level, the doctor or other QHP does not necessarily have to personally assess an independent historian's narrative or order or review tests or documents. These items would be considered when formulating the management plan. However, if these factors are used to determine the reported code level, independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the doctor or other QHP.
Choosing the E/M Service Level
Within each E/M category or subcategory, code descriptors define the specific details of the service, which may include place and or type of service; content of the service provided; nature of the presenting problem; and the time generally required to provide the service.
Most E/M services are provided at varying levels of intensity. The extent of the patient's illness or injury will determine the amount of provider's work and skill required to evaluate and treat the patient. This effort of the provider (when documented appropriately and supported by medical necessity) drives the E/M service level.
Each level of service has a unique description and requirement for its category or subcategory.
The Guidelines for E/M Services, along with the code descriptors, indicate that a "medically appropriate history and/or physical examination, when performed" is included in the service. While the history and exam should be documented, they are not used in the determination of the level of the code. The guidelines also include pertinent definitions for terms necessary to understand when determining the level of MDM. You should read through the definitions, and refer back to them as we go through the MDM components below.
The subcategory guidelines for E/M Services provide instructions for selecting the appropriate level of service based on the following:
The level of the medical decision making as defined for each service; or
The total time for E/M services performed on the date of the encounter.
The provider can determine whether the service is supported by MDM or total time. Payers may also have regulations on when MDM or total time is used. The history directs the provider to troubleshoot the chief complaint based on an interview with the patient. The exam portion is the provider's physical exam and evaluation of the patient. The medical decision making includes the number and complexity of the presenting problems, the data to be reviewed and analyzed, and the risk associated with the patient's condition.
Determining the Medical Decision Making (MDM)
The MDM most accurately reflects the amount of work a provider performs during an E/M service. Four levels of MDM are recognized: straightforward, low, moderate, and high. For services reported from the E/M category, the level of MDM directly correlates to a level of service.
To adequately determine the level of visit, the MDM is selected based on three components:
The number and complexity of problems addressed;
The amount and complexity of data to be reviewed and analyzed; and
The risk of complications and morbidity or mortality of patient management.
To determine the levels of these components appropriately, the definitions provided in your CPT code book must be understood. Using a grid method, we will discuss each component. Be sure to refer back to the definitions listed in the E/M Guidelines as needed.
Number and Complexity of Problems
The number and complexity of problems identifies the nature of the presenting problem and is based on the relative difficulty level in making a diagnosis. For the problem to be considered in the number of problems, the problem must be addressed within that encounter.
The final diagnosis alone does not determine the complexity or risk to the patient. The documentation should be reviewed for comorbidities or underlying diseases that are addressed that increase the level of risk to the patient. Presenting symptoms that are likely to represent a highly morbid condition may drive the MDM even when the ultimate diagnosis is not highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction. The term "risk" as used in these definitions relates to risk from the condition. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management. Simply listing a chronic illness in the documentation is not sufficient. The documentation should indicate that the provider addressed the conditions during the encounter or that the condition contributed to the severity of the case.
Per CPT, symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not, itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Multiple problems of a lower severity may, in aggregate, create higher risk due to interaction.
When a patient sees multiple providers for different aspects of their care, you may see a physician document the condition is being managed by another provider. When the documentation only states that the patient has the condition and that it is being treated by another provider, it is not considered for the leveling of the visit. If there is additional documentation showing assessment or care coordination regarding that diagnosis, other than the statement of the condition being treated by another provider, it is then considered toward the level of service.There are four levels identified under the number and complexity of problems addressed; minimal, low, moderate, and high. As demonstrated by the table below, the level of Number/Complexity of Problems Addressed increases as the difficulty of the patient's health increases.
| Number/Complexity of Problems Addressed - Nature of Present