Determine the Extent of Examination Performed

The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of examination that are defined as follows: 

Problem Focused - A limited examination of the affected body area or organ system. 

Expanded Problem Focused - A limited examination of the affected body area or organ system and other symptomatic or related organ system(s). 

Detailed - An extended examination of the affected body area(s) and other symptomatic or related organ system(s). 

Comprehensive - A general multisystem examination or a complete examination of a single organ system. Note: The comprehensive examination performed as part of the preventive medicine E/M service is multisystem, but its extent is based on age and risk factors identified.

For the purposes of these CPT® definitions, the following body areas are recognized: 

• Head, including the face; 

• Neck; 

• Chest, including breasts and axilla; 

• Abdomen; 

• Genitalia, groin, buttocks;

• Back; 

• Each extremity;

For the purposes of these CPT® definitions, the following organ systems are recognized:

• Eyes; 

• Ears, nose, mouth, and throat; 

• Cardiovascular; 

• Respiratory; 

• Gastrointestinal; 

• Genitourinary;

• Musculoskeletal; 

• Skin; 

• Neurologic; 

• Psychiatric;

• Hematologic/Lymphatic/Immunologic. 

 Determine the Complexity of Medical Decision Making: Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

• The number of possible diagnoses and/or the number of management options that must be considered; 

• The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and 

• The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options. 

Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless their presence significantly increases the complexity of the medical decision making.

 Select the Appropriate Level of E/M Services Based on the Following: 

1. For the following categories/subcategories, all of the key components ie, history, examination, and medical decision making, must meet or exceed the stated requirements to qualify for a particular level of E/M service: office, new patient; hospital observation services; initial hospital care; office consultations; initial inpatient consultations; emergency department services; initial nursing facility care; domiciliary care, new patient; and home, new patient. 

2. For the following categories/subcategories, two of the three key components (ie, history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M services: office, established patient; subsequent hospital care; subsequent nursing facility care; domiciliary care, established patient; and home, established patient. 

3. When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record.