Documentation Guidelines for CPT E&M Codes

Introduction

The Current Procedural Terminology (CPT) manual, published annually by the American Medical Association (AMA) has definitive documentation guidelines that are required for each level of service code within the various E&M categories.

The E&M categories for office/outpatient; office and in-patient consultations; and emergency room services each have five levels of coding.

The E&M categories of initial and subsequent hospital visits each have three levels of coding.

The seven components to the code selection are:

• The extent of History
• The extent of Exam
• The extent of Medical Decision Making
• New or established patient
• Nature of the presenting problem
• Counseling or coordination of care
• Amount of time spent with the patient

The charts that follow address the three KEY components to consider when selecting the level of code:

• History
• Exam
• Medical Decision Making

New patients and consultations require that the three key components be met or exceeded.

Established patients and subsequent visits require that two of the three key components be met or exceeded.

Code Selection

The information provided at the top of the chart for each category will inform you if three or two key components must be met or exceeded to select the code.

1. Select the appropriate level of history, exam, and medical decision making.
2. If a row has two or three circles, select the code associated with that row.
3. If several rows have one circle each, find the row that contains the second circle, and select the code associated with that row.

Determine the Level of HISTORY

CC=chief complaint; HPI=hx of present illness; ROS=review of systems; PFSH=past family social hx

Determine the Level of EXAMINATION

Determine the COMPLEXITY of MEDICAL DECISION MAKING

Decision Making (2 of 3 required)

• A. Number of diagnoses or management options: clinical impressions, referrals, changes in treatment.
• B. Amount and/or complexity of data to be reviewed: test and procedures ordered, reviewed, and /or discussed as well as old records reviewed.
• C. Risk of complexity/morbidity/mortality.

1. Dx and Management Options
Self-limiting/minor problem, stable, improved, worsening (pt.) max = 2
Established problem, stable, improved well controlled/resolving or resolved (1 pt.)
Established problem, worsening, failing to respond, inadequately controlled (2 pts.)
New Problem, no additional workup planned (3 pts.) max = 1
New problem with additional workup planned (4 pts.)

TOTAL = _______

2. Amount and /or Complexity of Data
Discuss tests with performing physician (1 pt.)
Ordered/reviewed labs/x-rays/tests from medicine section of CPT (1 pt.)
Decision to obtain old records/hx from someone other than the patient (1 pt.)
Independent review of tracings, specimens or x-rays (2 pts.)
Review/summarize old records /hx from someone other than the patient (2 pts.)

TOTAL = ________

Documentation Guidelines for CPT Evaluation and Management Services

Determine the Level of EXAMINATION

Determine the COMPLEXITY of MEDICAL DECISION MAKING

Decision Making (2 of 3 required)

• A. Number of diagnoses or management options: clinical impressions, referrals, changes in treatment.
• B. Amount and/or complexity of data to be reviewed: test and procedures ordered, reviewed, and /or discussed as well as old records reviewed.
• C. Risk of complexity/morbidity/mortality.

1. Dx and Management Options
Self-limiting/minor problem, stable, improved, worsening (pt.) max = 2
Established problem, stable, improved well controlled/resolving or resolved (1 pt.)
Established problem, worsening, failing to respond, inadequately controlled (2 pts.)
New Problem, no additional workup planned (3 pts.) max = 1
New problem with additional workup planned (4 pts.)

TOTAL = _______

2. Amount and /or Complexity of Data
Discuss tests with performing physician (1 pt.)
Ordered/reviewed labs/x-rays/tests from medicine section of CPT (1 pt.)
Decision to obtain old records/hx from someone other than the patient (1 pt.)
Independent review of tracings, specimens or x-rays (2 pts.)
Review/summarize old records /hx from someone other than the patient (2 pts.)

TOTAL = ________

Decision Making (2 of 3 required)

• A. Number of diagnoses or management options: clinical impressions, referrals, changes in treatment.
• B. Amount and/or complexity of data to be reviewed: test and procedures ordered, reviewed, and /or discussed as well as old records reviewed.
• C. Risk of complexity/morbidity/mortality.

1. Dx and Management Options
Self-limiting/minor problem, stable, improved, worsening (pt.) max = 2
Established problem, stable, improved well controlled/resolving or resolved (1 pt.)
Established problem, worsening, failing to respond, inadequately controlled (2 pts.)
New Problem, no additional workup planned (3 pts.) max = 1
New problem with additional workup planned (4 pts.)

TOTAL = _______

2. Amount and /or Complexity of Data
Discuss tests with performing physician (1 pt.)
Ordered/reviewed labs/x-rays/tests from medicine section of CPT (1 pt.)
Decision to obtain old records/hx from someone other than the patient (1 pt.)
Independent review of tracings, specimens or x-rays (2 pts.)
Review/summarize old records /hx from someone other than the patient (2 pts.)

TOTAL = ________

Table of Risk

Total is equal to the highest level of risk in any one category.

This table is to be used as a guideline for risk. It is not considered to be comprehensive.

TOTAL = _________

(Total = highest risk in any one category)

(Please note that Federal Payers, such as Medicare/Medicaid no longer recognize any category of consultation CPT Codes for reimbursement)

Outpatient/Office Coding

Inpatient Coding