Note: This article is provided for historical reference. It applies to coding prior to 2021. For information regarding updates, please see 99202-99215: Office/Outpatient E/M Coding in 2021 and 2023 E/M Coding Changes.
Evaluation and management coding is a type of medical coding used by physicians and certain other healthcare providers to report their services as part of medical billing. Evaluation and management (E/M) codes are found in the CPT ® code set in the range 99202-99499 and cover a variety of services. Many E/M codes, such as those for inpatient care and home visits, include a combination of patient history, examination, and medical decision making (MDM).
These factors — history, exam, and MDM (HEM) — are known as the three key components of E/M level selection. Determining the correct type of history, exam, and MDM can feel intimidating even for seasoned coders because of the many requirements involved. A solid understanding of these three key components will help ensure more accurate coding and reimbursement for E/M codes.
The following is an overview of how a provider selects an E/M code using the three key components of history, exam, and MDM. Different services may require different steps, such as when you report an E/M encounter based on time instead of using the key components, but this scenario will give you a sense of the general process used to code many E/M visits. The rest of the article will provide details on how to complete each step.
For this example, a physician sees a new patient for an E/M rest home visit. To report the rendered service, the physician must review the requirements for E/M codes 99324-99328. The physician follows the steps below to determine the appropriate E/M code from that group using the three key components.
1. Determine the type of history. A patient history includes getting the chief complaint and the history of the present illness. The history also may include a review of body systems using questions to identify signs and symptoms, and a review of the patient’s past, family, and social history, depending on what is medically appropriate for the visit. The amount of history taken will determine the type: problem focused, expanded problem focused, detailed, or comprehensive.
2. Determine the type of the physical exam. The provider uses clinical judgment to determine the extent of physical examination needed for each of the patient’s body areas and organ systems. The provider will document one of these four types of exam: problem focused, expanded problem focused, detailed, or comprehensive.
3. Determine the type of medical decision making (MDM). MDM is how the provider rates the degree of difficulty in establishing a patient’s diagnosis and treatment plan. E/M codes include four types of MDM: straightforward, low complexity, moderate complexity, and high complexity.
4. Determine the final code. Once the provider has determined the types of history, exam, and MDM, final E/M code selection can occur based on those three key components. For this example, assume the physician performed a comprehensive history, a comprehensive exam, and medical decision making of high complexity for this new patient. The appropriate code in this case is 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity ….
The first key component for E/M coding is history. As noted above, there are four types:
Not all types of codes that include history, exam, and MDM reference all four types of history. For instance, the lowest level initial hospital care code, 99221, requires a detailed or comprehensive history. The other two codes in that group, 99222 and 99223, each require a comprehensive history.
Also note that a small number of E/M code descriptors, specifically those for subsequent hospital care and subsequent nursing facility care, add the term “interval” before the type of history, such as “a comprehensive interval history.” Interval history is a history that focuses on the period since the patient’s last assessment, according to the January 2000 CPT ® Assistant newsletter, an authoritative publication by the American Medical Association (AMA).
To determine the type of history for an E/M code, you must be aware of these four elements:
The chief complaint (CC) is a brief statement explaining the reason for the encounter, such as the symptom, problem, condition, or diagnosis. Each of the four history types requires a chief complaint.
The other elements require more explanation, which you’ll find below. As part of the explanations, you’ll see references to the CPT ® E/M guidelines, which are the official guidelines published with the CPT ® code set. You’ll also see information from the Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. Many payers other than Medicare have adopted the 1995 and 1997 Documentation Guidelines, so familiarity with both the CPT and CMS guidelines is essential to accurate coding and reporting of E/M based on history, exam, and MDM.
History of present illness (HPI) is the portion of the E/M history component that describes the patient’s current illness. HPI covers development of the illness from the first sign or symptom to the current time.
The CPT ® guidelines for the E/M section list these elements for HPI: location, quality, severity, timing, context, modifying factors, and associated signs and symptoms with a significant relationship to the presenting problem or problems. The CMS 1995 and 1997 Documentation Guidelines add duration to this list.
According to CPT ® E/M guidelines, HPI may be brief or extended. The CMS 1995 and 1997 Documentation Guidelines help define these terms.
An example of a brief HPI for a patient with a chief complaint of earache may look like this: “Dull ache in left ear over the past 24 hours.” This brief HPI includes the three elements of quality (dull ache), location (in left ear), and duration (over the past 24 hours).
System review, or review of systems (ROS), is the part of an E/M history that involves asking about body systems to identify past and present signs and symptoms. A series of questions helps define the problem, clarify the differential diagnosis, identify testing needed, and provide baseline data about body systems related to treatment options.
The body systems listed by both the CPT ® guidelines and CMS 1995 and 1997 Documentation Guidelines are the same and are shown below.
Body Systems for ROS in E/M Coding
The CPT ® E/M guidelines refer to problem pertinent system review, “problem pertinent system review extended to include a review of a limited number of additional systems,” and “review of systems that is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems.”
For Medicare, these translate to problem pertinent, extended, or complete ROS. The 1995 and 1997 Documentation Guidelines define these terms:
The CMS Evaluation and Management Services guide includes this example of a complete ROS for a patient with a chief complaint of “fainting spell.” There are 10 systems documented in this complete ROS example.
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.
Past, family, and/or social history (PFSH) for E/M coding may be categorized as either pertinent or complete. As the PFSH name implies, this part of the E/M history component is a review of one or more of these three areas:
Pertinent PFSH is a review of areas related to the problems noted in the HPI. One item from any of the three areas will qualify as pertinent PFSH, according to the 1995 and 1997 Documentation Guidelines.
Complete PFSH is a review of two or all three of the areas. Whether you need two or three depends on the E/M service category, the 1995 and 1997 Documentation Guidelines state:
A pertinent PFSH example from the CMS Evaluation and Management Services Guide shows what review of relevant past surgical history for a patient with coronary artery disease might look like: “Follow-up of coronary artery bypass graft in 1992. Recent cardiac catheterization demonstrates 50 percent occlusion of vein graft to obtuse marginal artery.”
E/M categories that require only an interval history (such as subsequent hospital care and subsequent nursing facility care) don’t require PFSH, according to the 1995 and 1997 Documentation Guidelines.
Once you’ve determined the level of HPI, ROS, and PFSH, you can select the correct type of history for your E/M code using Table 1, taken from the CMS Evaluation and Management Services guide. You must meet all the elements in a row to qualify for that type of history.
*Meet all elements in a row to qualify for that history type