Welcome to the Supply Center

 

Evaluation and Management Codes
Kevin McNamee, D.C., L.Ac.

When a patient comes to your office for the initial visit, you perform a history, examination and make medical decisions based on the data collected.  This is what used to be called an office visit.  Unfortunately, the billing codes of the past included treatment in the office visit code. Some providers were providing uncovered services to patients but billing the office visit code in order to be paid for these treatments.  What should have happened was the patient paid the doctor directly for the uncovered services but the providers were trying to fraudulently circumvent the insurance terms of coverage, provide the service and be paid.

The Current Procedural Terminology (CPT), the universal billing codes used by providers, insured and third party payers for diagnostic and treatment services, was changed to include Evaluation and Management (E&M) Codes for this history, examination and medical decision making of the encounter. 

The E&M Codes are divided into level or complexity of the case evaluated.  The more difficult the condition, the higher the reimbursement. Likewise, the less difficult the case, the less the practitioner is paid.  Note that the reimbursement is based on the level or intensity of history, exam and medical decision-making done for the condition.  Thus, a stubbed toe would be at a low reimbursement level whereas a heart attack would be at a higher level. Several other factors, including the type of history and number of exam tests necessary to arrive at the diagnosis, influence the reimbursement level.

This E&M level is not based on time for what most practitioners spend during the initial visit.  Instead, it is based on the type of history, extent of the exam performed and the medical decision-making that was required.  This is best illustrated by the following:

A new practitioner conducts a history and exam of a patient which takes two hours to perform.  An experienced practitioner does the same history and exam, but due to the years of practice, is able to do the same history and examination tests in 15 minutes.  Same patient, same history, same examination in both cases.  Questions:  Why should the new practitioner be reimbursed more because he did an inefficient history and exam that took two hours?  Why should the experienced practitioner be penalized for doing an efficient history and examination which was completed in 15 minutes?  Each did the same amount of work in each case.  The E&M reimbursement is equal in both cases.

To determine the level of E&M to bill, follow these steps.

  • Is this a new or established patient? 

A new patient is one who has not received any professional services from the physician within the past three years.  Conversely, an established patient is one who has received professional services from the physician within the past three years.

  • Of the three KEY COMPONENTS, which are the HISTORY, EXAMINATION AND MEDICAL-DECISION MAKING, what level is each of these for the chief complaint?

HISTORY

  Present Illness or Problem   Systems Review   Family and/or Social History
Problem Focused Chief Complaint with Brief History    
Expanded Problem Focused Chief Complaint with Brief History & Problem pertinent  
Detailed Chief Complaint with Extended History Extended &   Pertinent past
Comprehensive Chief Complaint with Extended History   Complete &   Complete past

 

EXAMINATION

 Problem Focused Examination of affected body area or organ system
 Extended Problem Focused Examination of affected body area or organ system and other symptomatic or related organ system.
 Detailed

Extended exam of the affected body area(s) and other symptomatic or related organ system(s).

 Comprehensive

Complete, single system specialty exam or complete multi-system exam.

 

Medical Decision Making

Complexity of establishing a diagnosis and/or selecting a management option as measured by:

  1. Number of possible diagnosis and/or number of management options that must be considered

  2. Amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed/ and

  3. Risk of significant complications, morbidity and/or mortality, as well as co-morbidities, diagnostic procedures and/or management options.

To determine the type of decision making, 2 of the 3 elements must be met or exceeded.

Number of diagnosis or management options

Amount and/or complexity of data to be reviewed

Risk of complications and/or morbidity or mortality

Type of decision making

(Column 1) (Column 2) (Column 3) (Column 4)
minimal minimal or none minimal

straightforward

limited limited low low complexity

multiple

moderate moderate

moderate complexity

extensive extensive high high complexity

Note:  2 of the 3 elements must be met or exceeded (Column 1, 2 and 3) to determine the Type of Decision Making in the case (Column 4).

For example: A history and examination reveals that your patient has a limited number of diagnosis (Column 1); the amount and/or complexity of data is limited (Column 2) and the risk of complications and/or morbidity or mortality is minimal (Column 3) – is low complexity decision-making (Column 4).  This is because two of the three have been met or exceeded.

Note: Time is not one of the key factors if the History, Examination and Decision Making was more than 50% of the encounter.  Time becomes a factor in cases where you do counseling, or coordination of care with the family, etc., not when the majority of the encounter was doing the history, exam and medical decision-making.

   

New Patient Evaluation and Management
(Requires the first three components be met or exceeded)
   
99201 Problem Focused E/M – New Patient
a problem focused history;
a problem focused examination; and
straightforward medical decision-making.

10 minutes

  
 
99202 Expanded Problem Focused E/M – New Patient
an expanded problem focused history;
an expanded problem focused examination; and

straightforward medical decision-making.

20 minutes
     
 
99203 Detailed E/M – New Patient
a detailed history;
a detailed examination; and
medical decision making of low complexity.
30 minutes
 
 
99204  Comprehensive E/M – New Patient
a comprehensive history;
a comprehensive examination; and
medical decision making of moderate complexity.
45 minutes
 
   
99205  Complex E/M – New Patient
a comprehensive history;

a comprehensive examination; and

medical decision making of high complexity.
60 minutes
 
 
Established Patient Evaluation and Management
(Requires two of the three components be met or exceeded)
 
99211 Minimal E/M – Established Patient
Usually the presenting problem(s) are minimal.

5 minutes

 
 
99212 Problem Focused E/M – Established Patient
a problem focused history;
a problem focused examination; and
straightforward medical decision-making.
10 minutes
 
 
99213 Expanded Problem Focused E/M – Established Patient
an expanded problem focused history;
an expanded problem focused examination; and
medical decision making of low complexity.
15 minutes
 
 
99214 Detailed E/M – Established Patient
a detailed history;
a detailed examination; and
medical decision making of moderate complexity.
25 minutes
   
 
99215  Comprehensive E/M – Established Patient
a comprehensive history;
a comprehensive examination; and
medical decision making of high complexity.
40 minutes


The CPT codes change frequently. You will need to purchase a new edition every 2 to 3 years.  You can purchase a current copy from The Supply Center at 800-549-5993 or order online.

©The Supply Center / KM Enterprises
TERMS & POLICIES