Guidelines

Any specifically identifiable procedure (ie, identified with a specific CPT code) performed on or subsequent to the date of initial or subsequent E/M services should be reported separately.

The actual performance and/or interpretation of diagnostic test/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT® codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code with modifier 26 appended.

The physician or other health care professional may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant separately identifiable E/M service above and beyond other services provided or beyond the usual preservice and postservice care associated with the procedure that was performed. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date. 

 Nature of Presenting Problem: A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter. The E/M codes recognize five types of presenting problems that are defined as follows: 

Minimal - A problem that may not require the presence of the physician or other qualified health care professional, but service is provided under the physician’s or other qualified health care professional’s supervision.

Self-limited or Minor - A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance. 

Low severity - A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected. 

Moderate severity - A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.

High severity - A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.

 Past History: A review of the patient’s past experiences with illnesses, injuries, and treatments that includes significant information about: 

• Prior major illnesses and injuries; 

• Prior operations; 

• Prior hospitalizations; 

• Current medications; 

• Allergies (eg, drug, food); 

• Age appropriate immunization status; 

• Age appropriate feeding/dietary status. 

 Social History: An age appropriate review of past and current activities that includes significant information about:

• Marital status and/or living arrangements; 

• Current employment; 

• Occupational history; 

• Military history; 

• Use of drugs, alcohol, and tobacco; 

• Level of education; 

• Sexual history; 

• Other relevant social factors.  

 System Review (Review of Systems): An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. For the purposes of CPT®, the following elements of a system review have been identified:

• Constitutional symptoms (fever, weight loss, etc.);

• Eyes; 

• Ears, nose, mouth, throat;

• Cardiovascular; 

• Respiratory; 

• Gastrointestinal; 

• Genitourinary; 

• Musculoskeletal;

• Integumentary (skin and/or breast); 

• Neurological; 

• Psychiatric; 

• Endocrine; 

• Hematologic/Lymphatic; 

• Allergic/Immunologic.

The review of systems helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options.