Chief Complaint: A chief complaint is a concise statement describing the symptom,
problem, condition, diagnosis, or other factor that is the reason for the encounter,
usually stated in the patient’s words
Concurrent Care and Transfer of Care: Concurrent care is the provision of similar
services (eg, hospital visits) to the same patient by more than one physician or other
qualified health care professional on the same day. When concurrent care is provided,
no special reporting is required. Transfer of care is the process whereby a physician or
other qualified health care professional who is providing management for some or all
of a patient’s problems relinquishes this responsibility to another physician or other
qualified health care professional who explicitly agrees to accept this responsibility and
who, from the initial encounter, is not providing consultative services. The physician
or other qualified health care professional transferring care is then no longer providing
care for these problems though he or she may continue providing care for other
conditions when appropriate. Consultation codes should not be reported by the
physician or other qualified health care professional who has agreed to accept transfer
of care before an initial evaluation but are appropriate to report if the decision to accept
transfer of care cannot be made until after the initial consultation evaluation, regardless
of site of service
Counseling: Counseling is a discussion with a patient and/or family concerning one or
more of the following areas:
• Diagnostic results, impressions, and/or recommended diagnostic studies;
• Prognosis;
• Risks and benefits of management (treatment) options;
• Instructions for management (treatment) and/or follow-up;
• Importance of compliance with chosen management (treatment) options;
• Risk factor reduction; and
• Patient and family education.
(For psychotherapy, see 90832-90834, 90836-90840)
Family History: A review of medical events in the patient’s family that includes
significant information about:
• The health status or cause of death of parents, siblings and children;
• Specific diseases related to problems identified in the Chief Complaint or History of
the Present Illness, and/or System Review;
• Diseases of family members which may be hereditary or place the patient at risk.
History of Present Illness: A chronological description of the development of the
patient’s present illness from the first sign and/or symptom to the present. This includes
a description of location, quality, severity, timing, context, modifying factors, and
associated signs and symptoms significantly related to the presenting problem(s).
Levels of E/M Services: Within each category or subcategory of E/M service, there
are three to five levels of E/M services available for reporting purposes. Levels of E/M
services are NOT interchangeable among the different categories or subcategories of
service. For example, the first level of E/M services in the subcategory of office visit,
new patient, does not have the same definition as the first level of E/M services in the
subcategory of office visit, established patient.
The levels of E/M services include examinations, evaluations, treatments, conferences
with or concerning patients, preventive pediatric and adult health supervision, and
similar medical services, such as the determination of the need and/or location for
appropriate care. Medical screening includes the history, examination, and medical
decision-making required to determine the need and/or location for appropriate care
and treatment of the patient (eg, office and other outpatient setting, emergency
department, nursing facility). The levels of E/M services encompass the wide
variations in skill, effort, time, responsibility and medical knowledge required for the
prevention or diagnosis and treatment of illness or injury and the promotion of optimal
health. Each level of E/M services may be used by all physicians or other qualified
health care professionals.
The descriptors for the levels of E/M services recognize seven components, six of
which are used in defining the levels of E/M services. These components are:
• History;
• Examination;
• Medical decision making;
• Counseling;
• Coordination of care;
• Nature of presenting problem; and
• Time.
The first three of these components (history, examination and medical decision
making) are considered the key components in selecting a level of E/M services.
The next three components (counseling, coordination of care, and the nature of the
presenting problem) are considered contributory factors in the majority of encounters.
Although the first two of these contributory factors are important E/M services, it is not
required that these services be provided at every patient encounter.
Coordination of care with other physicians, other health care professionals, or agencies
without a patient encounter on that day is reported using the case management codes.
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