What are E&M Services?
E&M services are easily recognizable medical services such as a visit to urgent care, hospital admission, or daily rounds on people admitted to a hospital. These services have multiple levels which correspond to different levels of medical complexity, such as a ‘new outpatient visit – level 4’. Selecting the correct level of service is critical to being paid appropriately for the patient encounter. Medicare released guidelines on how to select the proper service level in 1995 and 1997. This Guide to E&M services provides a brief overview of the Documentation rules for E&M coding for physicians in the USA.
Not all medical services are covered under Guide to E&M Services. Surgeries, lab tests, preventative medicine, counseling, and imaging studies have separate documentation rules.
How can I use the Guide to E&M Services sheet to improve medical billing?
Use this E&M Guide to understand the documentation requirements for billing at each service level. Selecting the appropriate level for E&M services is challenging for most physicians. Studies show that 30-80% of outpatient E&M services are under coded, representing millions of dollars of lost practice revenue per year [Holt 2010].
What needs to be documented for E&M services?
The 1997 E&M Documentation Guidelines state that each patient encounter must include a medical history, examination, and medical decision making (MDM). Each documentation component requires certain types of information to be documented in the medical record.
Documentation Components from the 1997 Guidelines:
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Past Family and Social History (PFSH)
- Review of Systems (ROS)
Medical Decision Making (MDM)
- The number of diagnosis or management options
- Amount and complexity of medical data reviewed
- Risk of significant complications, morbidity, or mortality
References for the Guide to E&M Services
- Thinking on Paper: Guidelines for Documenting Medical Decision Making
- HGSA Documentation worksheet
- Holt J, Warsy A, Wright P. Medical decision making: guide to improved CPT coding. South Med J. 2010 Apr;103(4):316-22
- 1997 Documentation Guidelines for Evaluation and Management Services
- 1995 Documentation Guidelines for Evaluation and Management Services