Evaluation & management for coding & billing

EVALUATION & MANAGEMENT SERVICES GUIDE

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DISCLAIMER
This guide was current at the time it was published or uploaded onto the web. Medicare policy
changes frequently so links to the source documents have been provided within the document for
your reference.
This guide was prepared as a tool to assist providers and is not intended to grant rights or impose
obligations. Although every reasonable effort has been made to assure the accuracy of the
information within these pages, the ultimate responsibility for the correct submission of claims and
response to any remittance advice lies with the provider of services. The Centers for Medicare
& Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or
guarantee that this compilation of Medicare information is error-free and will bear no responsibility or
liability for the results or consequences of the use of this guide. This guide is a general summary that
explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare
Program provisions are contained in the relevant laws, regulations, and rulings.
MEDICARE LEARNING NETWORK
The Medicare Learning Network (MLN) is the brand name for official CMS educational products
and information for Medicare fee-for-service providers. For additional information visit the Medicare
Learning Network’s web page at http://www.cms.hhs.gov/MLNGenInfo on the CMS website.
ICD-9-CM NOTICE
The International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) is
published by the United States Government. A CD-ROM, which may be purchased through the
Government Printing Office, is the only official Federal government version of the ICD-9-CM. ICD-9-
CM is an official Health Insurance Portability and Accountability Act standard.
CPT DISCLAIMER AMERICAN MEDICAL ASSOCIATION (AMA) NOTICE AND DISCLAIMER
Current Procedural Terminology (CPT) only copyright 2008 American Medical Association. All rights
reserved. CPT is a registered trademark of the American Medical Association (AMA). Applicable
FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion
factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA
is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense
medical services. The AMA assumes no liability for data contained or not contained herein.

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PREFACE
This guide is offered as a reference tool and does not replace content found in the
1995 Documentation Guidelines for Evaluation and Management Services and the 1997
Documentation Guidelines for Evaluation and Management Services. It is recommended
that health care providers refer to the 1995 Documentation Guidelines for Evaluation and
Management Services in order to identify differences between the two sets of guidelines.
It is recommended that providers refer to the following publications, which were used to prepare
this guide:
1995 Documentation Guidelines for Evaluation and Management Services■■ , available at
http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf on the Centers for Medicare &
Medicaid Services (CMS) website;
1997 Documentation Guidelines for Evaluation and Management Services■■ , available at
http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf on the CMS website;
Medicare Claims Processing Manual (Pub. 100-4), available at■■
http://www.cms.hhs.gov/Manuals/IOM/list.asp on the CMS website; and
Current Procedural Terminology■■ book, available from the American Medical Association
(800-621-8335) or http://www.amapress.org on the Web).

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TABLE OF CONTENTS
Medical Record Documentation.................................................................................. 4
Common Sets of Codes.............................................................................................. 5
Key Elements of Service............................................................................................. 7
Acronyms.................................................................................................................. 22
Reference Materials.................................................................................................. 22

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MEDICAL RECORD DOCUMENTATION
“If it isn’t documented, it hasn’t been done” is an adage that is
frequently heard in the health care setting.
Concise medical record documentation is critical to providing patients with quality care as well as to
receiving accurate and timely reimbursement for furnished services. It chronologically documents
the care of the patient and is required to record pertinent facts, findings, and observations about the
patient’s health history including past and present illnesses, examinations, tests, treatments, and
outcomes. Medical record documentation also assists physicians and other health care professionals
in evaluating and planning the patient’s immediate treatment and monitoring his or her health care
over time.
Payers may require reasonable documentation that services are consistent with the insurance
coverage provided in order to validate:
The site of service;■■
The medical necessity and appropriateness of the diagnostic and/or therapeutic services■■
provided; and/or
That services furnished have been accurately reported.■■
To ensure that medical record documentation is accurate, the following principles should be followed:
The medical record should be complete and legible.■■
The documentation of each patient encounter should include:■■
Reason for the encounter and relevant history, physical examination findings, and prior■■
diagnostic test results.
Assessment, clinical impression, or diagnosis.■■
Medical plan of care.■■
Date and legible identity of the observer.■■
If not documented, the rationale for ordering diagnostic and other ancillary services should be■■
easily inferred.
Past and present diagnoses should be accessible to the treating and/or consulting physician.■■
Appropriate health risk factors should be identified.■■
The patient’s progress, response to and changes in treatment, and revision of diagnosis should■■
be documented.
The Current Procedural Terminology (CPT) and International Classification of Diseases,■■
9th
Edition, Clinical Modification (ICD-9-CM) codes reported on the health insurance claim form
or billing statement should be supported by the documentation in the medical record.
Documentation guidelines for teaching physicians, interns, and residents can be found in the Medicare Learning■■
Network (MLN) publication titled Guidelines for Teaching Physicians, Interns, and Residents. This and other MLN
publications are available at http://www.cms.hhs.gov/MLNGenInfo on the CMS website.

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COMMON SETS OF CODES
When billing for a patient’s visit, codes are selected that best represent the services furnished during
the visit. The two common sets of codes that are currently used are:
Diagnostic or International Classification of Diseases, 9■■ th
Edition, Clinical Modification
(ICD-9-CM) codes; and
Procedural or American Medical Association Current Procedural Terminology (CPT) codes.■■
These codes are organized into various categories and levels. It is the physician’s responsibility to
ensure that documentation reflects the services furnished and that the codes selected reflect those
services. The more work performed by the physician, the higher the level of code he or she may
bill within the appropriate category. The billing specialist or alternate source reviews the physician’s
documented services and assists with selecting codes that best reflect the extent of the physician’s
personal work necessary to furnish the services.
Evaluation and management (E/M) services refer to visits and consultations furnished by physicians.
Billing Medicare for a patient visit requires the selection of a CPT code that best represents the level
of E/M service performed. For example, there are five CPT codes that may be selected to bill for
office or other outpatient visits for a new patient:
99201 – Usually the presenting problem(s) are self limited or minor and the physician typically■■
spends 10 minutes face-to-face with the patient and/or family. E/M requires the following three
key components:
Problem focused history.■■
Problem focused examination.■■
Straightforward medical decision making.■■
99202 – Usually the presenting problem(s) are of low to moderate severity and the physician■■
typically spends 20 minutes face-to-face with the patient and/or family. E/M requires the
following three key components:
Expanded problem focused history.■■
Expanded problem focused examination.■■
Straightforward medical decision making.■■
99203 – Usually the presenting problem(s) are of moderate severity and the physician typically■■
spends 30 minutes face-to-face with the patient and/or family. E/M requires the following three
key components:
Detailed history.■■
Detailed examination.■■
Medical decision making of low complexity.■■
99204 – Usually the presenting problem(s) are of moderate to high severity and the physician■■
Comprehensive history.■■
Comprehensive examination.■■
Medical decision making of moderate complexity.■■
CPT only copyright 2008 American Medical Association. All rights reserved.

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99205 – Usually the presenting problem(s) are of moderate to high severity and the physician■■
Comprehensive history.■■
Comprehensive examination.■■
Medical decision making of high complexity.■■
International Classification of Diseases, 10th
Edition, Clinical Modification/Procedure
Coding System
The compliance date for implementation of
the International Classification of Diseases,
10th
Edition, Clinical Modification/Procedure
Coding System (ICD-10-CM/PCS) is October
1, 2013 for all Health Insurance Portability and
Accountability Act covered entities. ICD-10-CM/
PCS will enhance accurate payment for services
rendered and facilitate evaluation of medical
processes and outcomes. The new classification
system provides significant improvements
through greater detailed information and the
ability to expand in order to capture additional
advancements in clinical medicine.
ICD-10-CM/PCS consists of two parts:
ICD-10-CM – The diagnosis classification■■
system developed by the Centers for
Disease Control and Prevention for use
in all U.S. health care treatment settings. Diagnosis coding under this system uses 3 – 7 alpha
and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; and
ICD-10-PCS – The procedure classification system developed by the Centers for Medicare■■
& Medicaid Services (CMS) for use in the U.S. for inpatient hospital settings ONLY. The new
procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system
uses 3 or 4 numeric digits.
ICD-10-CM/PCS will not affect physicians, outpatient facilities, and hospital outpatient departments’
use of CPT codes on Medicare fee-for-service claims, as CPT will continue to be utilized.
To find additional information about ICD-10-CM/PCS, visit http://www.cms.hhs.gov/ICD10 on the
CMS website.

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KEY ELEMENTS OF SERVICE
To determine the appropriate level of service for a patient’s visit, it is necessary to first determine
whether the patient is new or already established. The physician then uses the presenting illness as a
guiding factor and his or her clinical judgment about the patient’s condition to determine the extent of
key elements of service to be performed. The key elements of service are:
History;■■
Examination; and■■
Medical decision making.■■
The key elements of service and documentation of an encounter dominated by counseling and/or
coordination of care are discussed below.
I. History
The elements required for each type of history are depicted in the table below. Note that each history
type requires more information as you read down the left hand column. For example, a problem
focused history requires the documentation of the chief complaint (CC) and a brief history of present
illness (HPI) and a detailed history requires the documentation of a CC, extended HPI, extended
review of systems (ROS), and pertinent past, family and/or social history (PFSH).
Elements Required for Each Type of History
TYPE OF HISTORY
CHIEF
COMPLAINT
HISTORY OF
PRESENT
ILLNESS
REVIEW OF
SYSTEMS
PAST, FAMILY,
AND/OR
SOCIAL
HISTORY
Problem Focused Required Brief N/A N/A
Expanded
Problem Focused
Required Brief Problem
Pertinent
N/A
Detailed Required Extended Extended Pertinent
Comprehensive Required Extended Complete Complete
The extent of information gathered for history is dependent upon clinical judgment and the nature
of the presenting problem. Documentation of patient history includes some or all of the following
elements:
A. Chief Complaint
A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason
for the patient encounter. The CC is usually stated in the patient’s own words. For example, patient
complains of upset stomach, aching joints, and fatigue.

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B. History of Present Illness
HPI is a chronological description of the development of the patient’s present illness from the first sign
and/or symptom or from the previous encounter to the present. HPI elements are:
Location. For example, pain in left leg;■■
Quality. For example, aching, burning, radiating;■■
Severity. For example, 10 on a scale of 1 to 10;■■
Duration. For example, it started three days ago;■■
Timing. For example, it is constant or it comes and goes;■■
Context. For example, lifted large object at work;■■
Modifying factors. For example, it is better when heat is applied; and■■
Associated signs and symptoms. For example, numbness.■■
There are two types of HPIs:
Brief, which includes documentation of one to three HPI elements. In the following example, three1.
HPI elements – location, severity, and duration – are documented:
CC: A patient seen in the office complains of left ear pain.■■
Brief HPI: Patient complains of dull ache in left ear over the past 24 hours.■■
Extended, which includes documentation of at least four HPI elements or the status of at least2.
three chronic or inactive conditions. In the following example, five HPI elements – location,
severity, duration, context, and modifying factors – are documented:
Extended HPI: Patient complains of dull ache in left ear over the past 24 hours. Patient states■■
he went swimming two days ago. Symptoms somewhat relieved by warm compress and
ibuprofen.
C. Review of Systems
ROS is an inventory of body systems obtained by asking a series of questions in order to identify
signs and/or symptoms that the patient may be experiencing or has experienced. The following
systems are recognized:
Constitutional Symptoms (e.g., fever, weight loss);■■
Eyes;■■
Ears, Nose, Mouth, Throat;■■
Cardiovascular;■■
Respiratory;■■
Gastrointestinal;■■
Genitourinary;■■
Musculoskeletal;■■
Integumentary (skin and/or breast);■■
Neurological;■■
Psychiatric;■■
Endocrine;■■
Hematologic/Lymphatic; and■■
Allergic/Immunologic.■■

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There are three types of ROS:
Problem pertinent, which inquires about the system directly related to the problem identified in the1.
HPI. In the following example, one system – the ear – is reviewed:
CC: Earache.■■
ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache.■■
Extended, which inquires about the system directly related to the problem(s) identified in the HPI2.
and a limited number (two to nine) of additional systems. In the following example, two systems –
cardiovascular and respiratory – are reviewed:
CC: Follow up visit in office after cardiac catheterization. Patient states “I feel great.”■■
ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness■■
of breath. Relates occasional unilateral, asymptomatic edema of left leg.
Complete, which inquires about the system(s) directly related to the problem(s) identified in the3.
HPI plus all additional (minimum of 10) body systems. In the following example, 10 signs and
symptoms are reviewed:
CC: Patient complains of “fainting spell.”■■
ROS:■■
Constitutional: weight stable, + fatigue.■■
Eyes: + loss of peripheral vision.■■
Ear, Nose, Mouth, Throat: no complaints.■■
Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema.■■
Respiratory: + shortness of breath on exertion.■■
Gastrointestinal: appetite good, denies heartburn and indigestion. + episodes of nausea.■■
Bowel movement daily; denies constipation or loose stools.
Urinary: denies incontinence, frequency, urgency, nocturia, pain, or discomfort.■■
Skin: + clammy, moist skin.■■
Neurological: + fainting; denies numbness, tingling, and tremors.■■
Psychiatric: denies memory loss or depression. Mood pleasant.■■
D. Past, Family, and/or Social History
PFSH consists of a review of the patient’s:
Past history including experiences with illnesses, operations, injuries, and treatments;■■
Family history including a review of medical events, diseases, and hereditary conditions that■■
may place him or her at risk; and
Social history including an age appropriate review of past and current activities.■■
The two types of PFSH are:
Pertinent, which is a review of the history areas directly related to the problem(s) identified in1.
the HPI. The pertinent PFSH must document one item from any of the three history areas. In the
following example, the patient’s past surgical history is reviewed as it relates to the current HPI:
Patient returns to office for follow up of coronary artery bypass graft in 1992. Recent cardiac■■
catheterization demonstrates 50 percent occlusion of vein graft to obtuse marginal artery.

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Complete, which is a review of two or all three of the areas, depending on the category of2.
evaluation and management (E/M) service. A complete PFSH requires a review of all three history
areas for services that, by their nature, include a comprehensive assessment or reassessment of
the patient. A review of two history areas is sufficient for other services. At least one specific item
from two of the three history areas must be documented for a complete PFSH for the following
categories of E/M services:
Office or other outpatient services, established patient;■■
Emergency department;■■
Domiciliary care, established patient; and■■
Home care, established patient.■■
At least one specific item from each of the history areas must be documented for the following
categories of E/M services:
Office or other outpatient services, new patient;■■
Hospital observation services;■■
Hospital inpatient services, initial care;■■
Consultations;■■
Comprehensive Nursing Facility assessments;■■
Domiciliary care, new patient; and■■
Home care, new patient.■■
In the following example, the patient’s genetic history is reviewed as it relates to the current HPI:
Family history reveals the following:■■
Maternal grandparents: both + for coronary artery disease; grandfather deceased at age■■
69; grandmother still living.
Paternal grandparents: grandmother - + diabetes, hypertension; grandfather - + heart■■
attack at age 55.
Parents: mother - + obesity, diabetes; father - + heart attack age 51, deceased age 57■■
of heart attack.
Siblings: sister - + diabetes, obesity, hypertension, age 39; brother - + heart attack at■■
age 45, living.

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II. Examination
An examination may involve several organ systems or a single organ system. The extent of the
examination performed is based upon clinical judgment, the patient’s history, and nature of the
presenting problem.
The chart below depicts the body areas and organ systems that are recognized according to the
Current Procedural Terminology (CPT) book:
Recognized Body Areas and Organ Systems
BODY AREAS ORGAN SYSTEMS
Head, including face■■
Neck■■
Chest, including breasts and■■
axilla
Abdomen■■
Genitalia, groin, buttocks■■
Back■■
Each extremity■■
Eyes■■
Ears, Nose, Mouth, and Throat■■
Cardiovascular■■
Respiratory■■
Gastrointestinal■■
Genitourinary■■
Musculoskeletal■■
Skin■■
Neurologic■■
Hematologic/Lymphatic/Immunologic■■
Psychiatric■■
There are two types of examinations that can be performed during a patient’s visit:
General multi-system examination, which involves the examination of one or more organ systems1.
or body areas. According to the 1997 Documentation Guidelines for Evaluation and Management
Services, each body area or organ system contains two or more of the following examination
elements:
Constitutional Symptoms (e.g., fever, weight loss);■■
Eyes;■■
Ears, Nose, Mouth, Throat;■■
Neck;■■
Respiratory;■■
Chest (breasts);■■
Gastrointestinal;■■
Lymphatic;■■
Integumentary;■■
Neurological; and■■
Psychiatric.■■

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Single organ system examination, which involves2.
a more extensive examination of a specific organ
system.
Both types of examinations may be performed by any
physician, regardless of specialty. The chart below
compares the elements of the cardiovascular system/
body area for both a general multi-system and single
organ system examination.
Cardiovascular System/Body Area
SYSTEM/
BODY AREA
GENERAL MULTI-SYSTEM
EXAMINATION
SINGLE ORGAN SYSTEM EXAMINATION
Cardiovascular Palpation of heart (e.g.,■■
location, size, thrills).
Auscultation of heart with■■
notation of abnormal sounds
and murmurs.
Examination of:■■
Carotid arteries (e.g.,■■
pulse amplitude, bruits)
Abdominal aorta (e.g.,■■
size, bruits);
Femoral arteries (e.g.,■■
pulse amplitude, bruits);
Pedal pulses (e.g., pulse■■
amplitude); and
Extremities for edema■■
and/or varicosities.
Palpation of heart (e.g., location, size,■■
and forcefulness of the point of maximal
impact; thrills; lifts; palpable S3 or S4).
Auscultation of heart including sounds,■■
abnormal sounds, and murmurs.
Measurement of blood pressure in two■■
or more extremities when indicated (e.g.,
aortic dissection, coarctation).
Examination of:■■
Carotid arteries (e.g., waveform,■■
pulse amplitude, bruits, apical-carotid
delay);
Abdominal aorta (e.g., size, bruits);■■
Femoral arteries (e.g., pulse■■
amplitude, bruits);
Pedal pulses (e.g., pulse amplitude);■■
and
Extremities for peripheral edema and/■■
or varicosities.

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The elements required for each type of examination are depicted in the table below.
Elements Required for Each Type of Examination
TYPE OF EXAMINATION DESCRIPTION
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 any other symptomatic or related
body area(s) or organ system(s).
Detailed An extended examination of the affected body area(s)
or organ system(s) and any other symptomatic or
related body areas(s) or organ system(s).
Comprehensive A general multi-system examination OR complete
examination of a single organ system and other
symptomatic or related body area(s) or organ
system(s).

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The elements required for general multi-system examinations are depicted in the following chart.
General Multi-System Examinations
TYPE OF EXAMINATION
DESCRIPTION
Problem Focused Include performance and documentation of 1 - 5
elements identified by a bullet in 1 or more organ
system(s) or body area(s).
Expanded Problem Focused Include performance and documentation of at least
6 elements identified by a bullet in 1 or more organ
Detailed Include at least 6 organ systems or body areas.
For each system/area selected, performance and
documentation of at least 2 elements identified
by a bullet is expected. Alternatively, may include
performance and documentation of at least 12
elements identified by a bullet in 2 or more organ
systems or body areas.
Comprehensive 1997 Documentation Guidelines for Evaluation and
Management Services:
Include at least 9 organ systems or body areas.
For each system/area selected, all elements of
the examination identified by a bullet should be
performed, unless specific directions limit the
content of the examination. For each area/system,
documentation of at least 2 elements identified by
bullet is expected.
1995 Documentation Guidelines for Evaluation and
Management Services:
Eight organ systems must be examined. If body
areas are examined and counted, they must be over
and above the 8 organ systems.
According to the 1997 Documentation Guidelines for Evaluation and Management Services, the 10
single organ system examinations are:
Ear, Nose, and Throat;■■
Eye;■■
Hematologic/Lymphatic/Immunologic;■■
Neurological;■■
Psychiatric;■■
Respiratory; and■■
Skin.■■

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The elements required for single organ system examinations are depicted in the following chart.
Single Organ System Examinations
TYPE OF EXAMINATION DESCRIPTION
Problem Focused Include performance and documentation of 1 - 5
elements identified by a bullet, whether in a box with a
shaded or unshaded border.
Expanded Problem Focused Include performance and documentation of at least 6
elements identified by a bullet, whether in a box with a
Detailed Examinations other than the eye and psychiatric
examinations should include performance and
documentation of at least 12 elements identified by a
bullet, whether in a box with a shaded or unshaded
border.
Eye and psychiatric examinations include the
performance and documentation of at least 9 elements
identified by a bullet, whether in a box with a shaded or
unshaded border.
Comprehensive Include performance of all elements identified by a
bullet, whether in a shaded or unshaded box.
Documentation of every element in each box with a
shaded border and at least 1 element in a box with an
unshaded border is expected.

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The chart below compares the elements that are required for both general multi-system and single
organ system examinations.
Multi-System and Single Organ Examinations
TYPE OF
EXAMINATION
MULTI-SYSTEM
EXAMINATIONS
SINGLE ORGAN SYSTEM
EXAMINATIONS
Problem Focused 1 - 5 elements identified by
a bullet in 1 or more organ
1 - 5 elements identified by a bullet,
whether in a box with a shaded or
unshaded border.
Expanded Problem
Focused
At least 6 elements identified
by a bullet in 1 or more organ
At least 6 elements identified by
a bullet, whether in a box with a
Detailed At least 6 organ systems or
body areas. For each system/
area selected, performance
and documentation of at least 2
elements identified by a bullet is
expected.
OR
At least 12 elements identified
by a bullet in 2 or more organ
systems or body areas.
At least 12 elements identified by
a bullet, whether in a box with a
Eye and psychiatric: At least 9
elements identified by a bullet,
whether in a box with a shaded or
unshaded border.
Comprehensive Include at least 9 organ systems
or body areas. For each system/
area selected, all elements of
the examination identified by
a bullet should be performed,
unless specific directions limit
the content of the examination.
For each area/system,
documentation of at least 2
elements identified by bullet is
expected.
Perform all elements identified by
a bullet, whether in a shaded or
unshaded box.
Document every element in each
box with a shaded border and at
least 1 element in a box with an
unshaded border.
Some important points that should be kept in mind when documenting general multi-system and
single organ system examinations are:
Specific abnormal and relevant negative findings of the examination of the affected or■■
symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal”
without elaboration is not sufficient;
Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or■■
organ system(s) should be described; and
A brief statement or notation indicating “negative” or “normal” is sufficient to document normal■■
findings related to unaffected area(s) or asymptomatic organ system(s). (However, an entire
organ system should not be documented with a statement such as “negative.”)

17
III. Medical Decision Making
Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a
management option, which is determined by considering the following factors:
The number of possible diagnoses and/or the number of management options that must be■■
considered;
The amount and/or complexity of medical records, diagnostic tests, and/or other information■■
that must be obtained, reviewed and analyzed; and
The risk of significant complications, morbidity, and/or mortality as well as comorbidities■■
associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the
possible management options.
The chart below depicts the elements for each level of medical decision making. Note that to
qualify for a given type of medical decision making, two of the three elements must either be met or
exceeded.
Elements of Medical Decision Making
TYPE OF
DECISION
MAKING
NUMBER OF
DIAGNOSES OR
MANAGEMENT
OPTIONS
AMOUNT AND/
OR COMPLEXITY
OF DATA TO BE
REVIEWED
RISK OF
SIGNIFICANT
COMPLICATIONS,
MORBIDITY, AND/
OR MORTALITY
Straightforward Minimal Minimal or None Minimal
Low Complexity Limited Limited Low
Moderate
Complexity
Multiple Moderate Moderate
High
Complexity
Extensive Extensive High
Number of Diagnoses or Management Options
The number of possible diagnoses and/or the number of management options that must be
considered is based on:
The number and types of problems addressed during the encounter;■■
The complexity of establishing a diagnosis; and■■
The management decisions that are made by the physician.■■
In general, decision making with respect to a diagnosed problem is easier than that for an identified but
undiagnosed problem. The number and type of diagnosed tests performed may be an indicator of the
number of possible diagnoses. Problems that are improving or resolving are less complex than those
problems that are worsening or failing to change as expected. Another indicator of the complexity of
diagnostic or management problems is the need to seek advice from other health care professionals.

18
Some important points that should be kept in mind when documenting the number of diagnoses or
management options are:
For each encounter, an assessment, clinical impression, or diagnosis should be documented■■
which may be explicitly stated or implied in documented decisions regarding management
plans and/or further evaluation.
For a presenting problem with an established diagnosis, the record should reflect■■
whether the problem is:
Improved, well controlled, resolving, or resolved.-
Inadequately controlled, worsening, or failing to change as expected.-
For a presenting problem without an established diagnosis, the assessment or clinical■■
impression may be stated in the form of differential diagnoses or as a “possible,”
“probable,” or “rule out” diagnosis
The initiation of, or changes in, treatment should be documented. Treatment includes a wide■■
range of management options including patient instructions, nursing instructions, therapies,
and medications.
If referrals are made, consultations requested, or advice sought, the record should indicate to■■
whom or where the referral or consultation is made or from whom advice is requested.
Amount and/or Complexity of Data to be Reviewed
The amount and/or complexity of data to be reviewed is based on the types of diagnostic testing
ordered or reviewed. Indications of the amount and/or complexity of data being reviewed include:
A decision to obtain and review old medical records and/or obtain history from sources other■■
than the patient (increases the amount and complexity of data to be reviewed);
Discussion of contradictory or unexpected test results with the physician who performed or■■
interpreted the test (indicates the complexity of data to be reviewed); and
The physician who ordered a test personally reviews the image, tracing, or specimen to■■
supplement information from the physician who prepared the test report or interpretation
(indicates the complexity of data to be reviewed).
Some important points that should be kept in mind when documenting amount and/or complexity of
data to be reviewed include:
If a diagnostic service is ordered, planned, scheduled, or performed at the time of the E/M■■
encounter, the type of service should be documented.
The review of laboratory, radiology, and/or other diagnostic tests should be documented.■■
A simple notation such as “White blood count elevated” or “Chest x-ray unremarkable” is
acceptable. Alternatively, the review may be documented by initialing and dating the report that
contains the test results.
A decision to obtain old records or obtain additional history from the family, caretaker, or other■■
source to supplement information obtained from the patient should be documented.
Relevant findings from the review of old records and/or the receipt of additional history from■■
the family, caretaker, or other source to supplement information obtained from the patient
should be documented. If there is no relevant information beyond that already obtained, this
fact should be documented. A notation of “Old records reviewed” or “Additional history obtained
from family” without elaboration is not sufficient.
Discussion about results of laboratory, radiology, or other diagnostic tests with the physician■■
who performed or interpreted the study should be documented.
The direct visualization and independent interpretation of an■■ image, tracing, or specimen
previously or subsequently interpreted by another physician should be documented.

19
Risk of Significant Complications, Morbidity, and/or Mortality
The risk of significant complications, morbidity, and/or mortality is based on the risks associated with
the following categories:
Presenting problem(s);■■
Diagnostic procedure(s); and■■
Possible management options.■■
The assessment of risk of the presenting problem(s) is based on the risk related to the disease
process anticipated between the present encounter and the next encounter. The assessment of
risk of selecting diagnostic procedures and management options is based on the risk during and
immediately following any procedures or treatment. The highest level of risk in any one category
determines the overall risk.
The level of risk of significant complications, morbidity, and/or mortality can be:
Minimal;■■
Low;■■
Moderate; or■■
High.■■
Some important points that should be kept in mind when documenting level of risk are:
Comorbidities/underlying diseases or other factors that increase the complexity of medical■■
decision making by increasing the risk of complications, morbidity, and/or mortality should be
documented;
If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of■■
the E/M encounter, the type of procedure should be documented;
If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the■■
specific procedure should be documented; and
The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent■■
basis should be documented or implied.
The table on the following page may be used to assist in determining whether the level of risk of
significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because
determination of risk is complex and not readily quantifiable, the table includes common clinical
examples rather than absolute measures of risk.

20
TABLE OF RISK
Level of
Risk
Presenting Problem(s)
Diagnostic Procedure(s)
Ordered
Management Options
Selected
Minimal
One self-limited or minor problem,ƒƒ
eg, cold, insect bite, tinea corporis
Laboratory tests requiringƒƒ
venipuncture
Chest x-raysƒƒ
EKG/EEGƒƒ
Urinalysisƒƒ
Ultrasound, eg,ƒƒ
echocardiography
KOH prepƒƒ
Restƒƒ
Garglesƒƒ
Elastic bandagesƒƒ
Superficial dressingsƒƒ
Low
Two or more self-limited or minorƒƒ
problems
One stable chronic illness, eg,ƒƒ
well controlled hypertension,
non-insulin dependent diabetes,
cataract, BPH
Acute uncomplicated illness orƒƒ
injury, eg, cystitis, allergic rhinitis,
simple sprain
Physiologic tests not underƒƒ
stress, eg, pulmonary
function tests
Non-cardiovascular imagingƒƒ
studies with contrast, eg,
barium enema
Superficial needle biopsiesƒƒ
Clinical laboratory testsƒƒ
requiring arterial puncture
Skin biopsiesƒƒ
Over-the-counter drugsƒƒ
Minor surgery with no identifiedƒƒ
risk factors
Physical therapyƒƒ
Occupational therapyƒƒ
IV fluids without additivesƒƒ
Moderate
One or more chronic illnesses withƒƒ
mild exacerbation, progression, or
side effects of treatment
Two or more stable chronicƒƒ
illnesses
Undiagnosed new problem withƒƒ
uncertain prognosis, eg, lump in
breast
Acute illness with systemicƒƒ
symptoms, eg, pyelonephritis,
pneumonitis, colitis
Acute complicated injury, eg,ƒƒ
head injury with brief loss of
consciousness
Physiologic tests underƒƒ
stress, eg, cardiac stress
test, fetal contraction stress
test
Diagnostic endoscopies withƒƒ
no identified risk factors
Deep needle or incisionalƒƒ
biopsy
Cardiovascular imagingƒƒ
studies with contrast and
no identified risk factors,
eg, arteriogram, cardiac
catheterization
Obtain fluid from bodyƒƒ
cavity, eg, lumbar puncture,
thoracentesis, culdocentesis
Minor surgery with identifiedƒƒ
risk factors
Elective major surgery (open,ƒƒ
percutaneous or endoscopic)
with no identified risk factors
Prescription drug managementƒƒ
Therapeutic nuclear medicineƒƒ
IV fluids with additivesƒƒ
Closed treatment of fracture orƒƒ
dislocation without manipulation
High
One or more chronic illnesses withƒƒ
severe exacerbation, progression,
or side effects of treatment
Acute or chronic illnesses orƒƒ
injuries that pose a threat to life
or bodily function, eg, multiple
trauma, acute MI, pulmonary
embolus, severe respiratory
distress, progressive severe
rheumatoid arthritis, psychiatric
illness with potential threat to self
or others, peritonitis, acute renal
failure
An abrupt change in neurologicƒƒ
status, eg, seizure, TIA,
weakness, sensory loss
Cardiovascular imagingƒƒ
studies with contrast with
identified risk factors
Cardiac electrophysiologicalƒƒ
tests
Diagnostic Endoscopies withƒƒ
identified risk factors
Discographyƒƒ
Elective major surgery (open,ƒƒ
percutaneous or endoscopic)
with identified risk factors
Emergency major surgeryƒƒ
(open, percutaneous or
endoscopic)
Parenteral controlledƒƒ
substances
Drug therapy requiring intensiveƒƒ
monitoring for toxicity
Decision not to resuscitate orƒƒ
to de-escalate care because of
poor prognosis

21
IV. Documentation of an Encounter Dominated by Counseling and/or Coordination
of Care
When counseling and/or coordination of care dominates (more than 50 percent of) the physician/
patient and/or family encounter (face-to-face time in the office or other outpatient setting, floor/unit
time in the hospital, or Nursing Facility), time is considered the key or controlling factor to qualify
for a particular level of E/M services. If the level of service is reported based on counseling and/or
coordination of care, the total length of time of the encounter should be documented and the record
should describe the counseling and/or activities to coordinate care. For example, if 25 minutes was
spent face-to-face with an established patient in the office and more than half of that time was spent
counseling the patient or coordinating his or her care, CPT code 99214 should be selected.
The Level I and Level II CPT books available from the American Medical Association list average
time guidelines for a variety of E/M services. These times include work done before, during, and after
the encounter. The specific times expressed in the code descriptors are averages and, therefore,
represent a range of times that may be higher or lower depending on actual clinical circumstances.

22
ACRONYMS
AMA American Medical Association
CC Chief Complaint
CMS Centers for Medicare & Medicaid Services
CPT Current Procedural Terminology
E/M Evaluation and Management
HPI History of Present Illness
ICD-9-CM International Classification of Diseases, 9th
Edition, Clinical Modification
ICD-10-CM/PCS International Classification of Diseases, 10th
Edition, Clinical Modification/
Procedure Coding System
PFSH Past, Family, and/or Social History
ROS Review of Systems
REFERENCE MATERIALS
Centers for Medicare & Medicaid Services
Documentation Guidelines for E&M Services
http://www.cms.hhs.gov/MLNEdWebGuide/25_
EMDOC.asp
Internet-Only Manuals
http://www.cms.hhs.gov/Manuals/IOM/list.asp
ICD-10-CM/PCS Resources and Information
http://www.cms.hhs.gov/icd10
Medicare Learning Network
http://www.cms.hhs.gov/MLNGenInfo
Other Organizations
Level I and Level II CPT Books
American Medical Association
(800) 621-8335
http://www.amapress.org
ICD-9-CM CD-ROM
Government Printing Office
U.S. Government Bookstore
(866) 512-1800
http://bookstore.gpo.gov

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