Codes and Documentation for Evaluation and Management Services

The evaluation and management (E/M) codes were introduced in the 1992 update to the fourth edition of Physicians’ Current Procedural Terminology (CPT). These codes cover a broad range of services for patients in both inpatient and outpatient settings. In 1995 and again in 1997, the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services, or CMS) published documentation guidelines to support the selection of appropriate E/M codes for services provided to Medicare beneficiaries. The major difference between the two sets of guidelines is that the 1997 set includes a single-system psychiatry examination (mental status examination) that can be fully substituted for the comprehensive, multisystem physical examination required by the 1995 guideline. Because of this, it clearly makes the most sense for mental health practitioners to use the 1997 guidelines (see Appendix E). A practical 27-page guide from CMS on how to use the documentation guidelines can be found at http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv _guide.pdf. The American Medical Association’s CPT manual also provides valuable information in the introduction to its E/M section. Clinicians currently have the option of using the 1995 or 1997 CMS documentation guidelines for E/M services, although for mental health providers the 1997 version is the obvious choice.

The E/M codes are generic in the sense that they are intended to be used by all physicians, nurse-practitioners, and physician assistants and to be used in primary and specialty care alike. All of the E/M codes are available to you for reporting your services. Psychiatrists frequently ask, “Under what clinical circumstances would you use the office or other outpatient service E/M codes in lieu of the psychiatric evaluation and psychiatric therapy codes?” The decision to use one set of codes over another should be based on which code most accurately describes the services provided to the patient. The E/M codes give you flexibility for reporting your services when the service provided is more medically oriented or when counseling and coordination of care is being provided more than psychotherapy.

THE E/M CODES

• E/M codes are used by all physician specialties and all other duly licensed health providers. 
• The definitions of new patient and established patient are important because of the extensive use of these terms throughout the guidelines in the E/M section. A new patient is defined as one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group within the past 3 years. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group within the past 3 years. When a physician is on call covering for another physician, the decision as to whether the patient is new or established is determined by the relationship of the covering physician to the physician group that has provided care to the patient for whom the coverage is now being provided. If the doctor is in the same practice, even though she has never seen the patient before, the patient is considered established. There is no distinction made between new and established patients in the emergency department

The other terms used in the E/M descriptors are equally as important. The terms that follow are vital to correct E/M coding

• Problem-focused history 

• Detailed history 

• Expanded problem-focused history 

• Comprehensive history

• Problem-focused examination

• Detailed examination

• Expanded problem-focused examination

• Comprehensive examination

• Straightforward medical decision making 

• Low-complexity medical decision making

• Moderate-complexity medical decision making

• High-complexity medical decision making 

• E/M codes have three to five levels of service based on increasing amounts of work. 

• Most E/M codes have time elements expressed as the time “typically” spent face-to-face with the patient and/or family for outpatient care or unit floor time for inpatient care. 

• For each E/M code it is noted that “Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.” When this counseling and coordination of care accounts for more than 50% of the time spent, the typical time given in the code descriptor may be used for selecting the appropriate code rather than the other factors. (See p. 44 for a discussion of counseling and coordination of care.) 

• The 1995 and 1997 CMS documentation guidelines for E/M codes have become the basis for sometimes draconian compliance requirements for clinicians who treat Medicare beneficiaries. Commercial payers have adopted elements of the documentation system in a variable manner. The fact is that the documentation guidelines cannot be ignored by practitioners. To do so would place the practitioner at risk for audits, civil actions by payers, and perhaps even criminal charges and prosecution by federal agencies.