LEVELS OF SERVICE SELECTION FOR EVALUATION AND MANAGEMENT CODES

The components of an E/M services code are history, exam, medical decision-making, counseling, coordination of care, nature of the presenting problem and time.

Requirement for New/Consult Patient vs. Established Patient

The history, exam and medical decision-making need to be at the same level or higher to support the level of care for a new patient or consult. For an established patient encounter, two of the three components must be at the same level or higher to support the level of care. The history and/or exam must be appropriate to the patient’s presenting problem; therefore, medical decision-making always will be one of the components for an established patient encounter.

History Component 

History components include history of the present illness (HPI), review of systems (ROS) and family and social history. The details of each history component are listed below.

HPI: 

• Chief complaint – reason for encounter 

• Location – specific to area of body 

• Quality – pain described as dull or sharp; wound described as jagged, dirty or clean 

• Severity – measured on a scale 

• Duration – how long the complaint has lasted 

• Context – how the complaint occurred 

• Modifying factors – what has alleviated symptoms 

• Signs and symptoms – additional information from the patient

In 2007, the CMS carriers clarified that the HPI component must be obtained by the physician. Although ancillary staff may question the patient regarding the chief complaint, that activity does not meet criteria for documentation of the HPI. The informationgatheredbyancillarystaff(e.g.,registered nurse, licensed practical nurse or medical assistant) may be used as preliminary information, but needs to be confirmed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician must review the information as documented, recorded or scribed and must write a notation that he/she reviewed it for accuracy and performed it as written (adding to it as necessary) and signing his/her name.