Evaluation Management Codes Analytical Report

The Purpose of E/M Codes

E/M codes are generic and are intended for use by all medical practitioners including nurse-practitioners, physicians and physician assistants. They can be used in both specialty care and primary care. All E/M codes can be used for reporting services. The decision on which E/M code to use is informed by which code describes most accurately the service the patient is to receive. The flexibility of E/M codes allows for easy and flexible reporting when service provided has more medical content or when more of coordination and counseling of care is given than psychotherapy (Codes and Documentation for Evaluation and Management Services).


The Creator of E/M Codes

E/M codes were created by the E/M Guidelines. The E/M Guidelines documents what is required for all E/M code documentations. The Centre for Medicare and Medicaid Services (CMS) together with the American Medical Association developed the E/M guidelines. So far, two versions of the guidelines have been released. The first one was released in 1995 while the second one was released in 1997. The E/M guidelines outline what is required for individual E/M codes given the extent of documentation of three significant components. Generally, E/M codes that attract the highest fees such as initial visits and consultations require more thorough documentation than the other codes that attract much lower fees such as hospital progress notes or visits made by an established client/patient (Physician-to-Physician E/M Compliance Solutions 2003).


Summarize the 3 key components of E/M documentation


Key Components

While selecting E/M services, the key components to pay attention to are Examination, Medical Decision Making and History. The three components are always captured in the descriptors for outpatient services, home services, domiciliary care services, nursing facility services, emergency department services, consultations, hospital inpatient services and hospital observation services (Kane, Reinertsen & Scottong, 2011).




The extent to which history is documented depends on the judgment of the physician as well as the nature of the problem or illness. There are different kinds of history and they include:




• Chief Complaint;


• A brief history of the problem or present illness


Expanded Problem-Focused


• Chief Complaint;


• A Brief history of the problem or present illness


• Problem-pertinent system review




• Chief complaint


• A brief history of the problem or present illness


• Extended system review


• Pertinent social, family and past history




• Chief complaint


• An extended history of the problem or present illness


• Complete system review


• A complete social, family and past history


Each kind of history detailed above covers some or all of the components below:


a) Chief Complaint — it is a definite statement stating the symptom, condition, problem, diagnosis, return recommended by physician, or any other factors contributing to the encounter (Painter). A chief complaint has to be stated at every level for any kind of history to be qualified for.


b) History of Present Illness (HPI) — it is a description made in a chronological order of the presenting problem or illness from the very first symptom or sign or from the initial encounter to the current one. HPI can be either brief or extended and the two are differentiated by the depth of detail involved in documentation. A brief one has one to three elements while an extended one can have four or more elements (1997 criteria only).


c) Past, Family and Social History (PFSH) — past history covers the history of significant illnesses, injuries, hospitalizations, allergies, age appropriate immunization status and allergies. Family history has to do with a record of the state of health of parents, children, siblings and the causes of death of these members of the family. It also covers health complaints that are connected with the presenting illness. Social history has to do with marital status/living arrangements, employment status, professional history, drug use history, sexual history and other social factors that are relevant to the current situation (Evaluation and Management (E/M Services).


2. Physical Examination


The extent and nature of examination done and documented depends on the judgment of the clinician, the history of the patient as well as the nature and kind of the presenting problem. A physical examination can be an evaluation of just one body part to an evaluation of a multi-system or a thorough evaluation of an organ system.


a. Types of examinations


There are four kinds of examinations upon which E/M services are based upon:


• Problem Focused — involves a limited evaluation of just the organ or part of body affected.


• Expanded Problem Focused — involves a limited evaluation of the affected organ system or area as well as the connected or related areas or organ systems.


• Detailed — this is an extended detailed examination of the body areas or organ systems affected as well as related or symptomatic organ systems or body areas.


• Comprehensive — this examination encapsulates at several systems or a complete and thorough evaluation of an organ system plus other related areas, organ systems and symptomatic areas (Evaluation and Management (E/M) Services).


3. Medical Decision Making


Medical decision making involves the process of establishing diagnoses or selection of management options. The 1997 and 1995 criteria do not vary much in this regard and share the same documentation requirements. E/M service levels recognize the following four kinds of medical decision making:




• Minimal number of diagnoses and management options are considered


• Minimal risk of morbidity, complications or mortality. There is expectation that the patient will fully recover without facing any functional impairments.


Low Complexity


• Limited number of management options or diagnoses are considered


• Limited complexity and volume of data is reviewed


• The risk of morbidity, complications or mortality is low.


Moderate Complexity


• Multiple diagnoses and/or management options are considered


• Data reviewed is of moderate complexity and volume


• There is moderate risk of morbidity, complications or morbidity


High Complexity


• An extensive and comprehensive number of diagnoses and/or management options are considered


• Data reviewed is of extensive complexity and volume


• There is a high risk of morbidity, complications and mortality.




a. Management Options


The types and number of problems encountered determine the kind of diagnoses considered and chosen. Management options considered are also pegged on these variables.


Presenting problems are grouped into various types as indicated below;


1. Minimal — the problem does not require a physician to be present but service has to be administered under the supervision of a physician.


2. Self-limited or minor — the problem is transient, runs a prescribed and defined course and is not very likely to alter the health status of the patient permanently. The prognosis, management and compliance are all good.


3. Low severity — the problem does not pose a high risk of morbidity even without treatment; the risk of mortality where there is no treatment is low and the patient recovers without being functionally impaired.


4. Moderate severity — this is a situation with moderate risk of morbidity and mortality, with no known treatment and where there in increased probability of the patient being functionally impaired and the prognosis is uncertain.


5. High severity — the problem is characterized by a high to extreme risk of morbidity without known (established) treatment and moderate mortality risk or a high probability of prolonged severe functional impairment that has no known treatment.


For every encounter, a diagnosis, clinical impression or assessment has to be documented. It can be an explicit documentation or implicit in the decisions made as pertains to the methods and extent of management and succeeding evaluations.


b. Data Complexity that is to be Appraised


The complexity and amount of information to be appraised depends on the reviewed or ordered diagnostic testing. If a decision is made to acquire as well as further review a patient’s medical history and records from a source excluding the patient, the volume as well as complexity of information that has to be reviewed increases.


c. Risk of Morbidity, Significant Complications and Mortality


The risk of morbidity, significant complications or mortality depends on the risks connected with the presenting issue, the diagnostic process as well as with the management options considered. Information to be considered includes the following:


• Comorbidities or underlying ailments or factors that lead to a rise in the difficulty of the medical decision by enhancing the risk involving morbidity, complications and mortality ought to be recorded.


• If an invasive or surgical diagnostic process has been carried out during the E/M encounter, the process ought to be recorded.


• The decision to carry out, or referral for, an invasive or surgical process on an immediate basis ought to be recorded or implicitly covered (Evaluation and Management (E/M) Services).


One legal and one ethical dilemma surrounding E/M coding and propose strategies for resolution


Ethical dilemma:


An ethical dilemma would be to bill for a service that was not carried out or to misrepresent the kinds of services administered.


Strategy to resolution


Training and educational programs on CPT codes ought to emphasize the significance of documentation to help detail the time the physician spent evaluating the patient. E&M coding has five levels (99201 — 99205) and each one requires increased specification during documentation so as to justify and explain the levels of reimbursement (Rudman et al. 2009).


Legal dilemma:


One legal dilemma would be committing fraud by misrepresenting services using incorrect codes. This can be willfully done for several reasons including to defraud a healthcare benefit program.


Strategy for resolution:


Resolution Strategy involves implementing an abuse and fraud education or training program which can be facilitated by coding committee which shall also set and enforce coding standards as well as protocols. Such a committee shall consist of financial administrators, nurses, physicians and health information management staff (Rudman et al. 2009).




Codes and Documentation for Evaluation and Management Services. Retrieved January 10, 2017, from https://www.cms.gov/Outreach-and…/eval-mgmt-serv-guide-ICN006764.pdf


Evaluation and Management (E/M) Services. Retrieved January 10, 2017, from http://ahc.buffalo.edu/docs/Compliance-E-M-Training-Guide.pdf


Kane, G., Reinertsen, L., & Sottong, E. (2011). Department of Health and Human Services Centers for Medicare & Medicaid Services.


Painter, F. THE 3 KEY COMPONENTS OF THE E/M GUIDELINES. Retrieved January 10, 2017, from http://www.chiro.org/LINKS/ABSTRACTS/Three_Key_Components.shtml


Physician-to-Physician E/M Compliance solutions (2003). Retrieved January 10, 2017, from http://emuniversity.com/Definitions.html


Rudman, W. J., Eberhardt, J. S., Pierce, W., & Hart-Hester, S. (2009). Healthcare fraud and abuse. Perspectives in Health Information Management/AHIMA, American Health Information Management Association, 6(Fall).

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