UNLISTED SERVICE

An E/M service may be provided that is not listed in this section of CPT®. When reporting such a service, the appropriate unlisted code may be used to indicate the service, identifying it by “Special Report,” as discussed in item D. The “Unlisted Services” and accompanying codes for the E/M section are as follows:

99429 Unlisted preventive medicine service 

99499 Unlisted evaluation and management service

SPECIAL REPORT: An unlisted service or one that is unusual, variable, or new may require a special report demonstrating the medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service. Additional items that may be included are complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care.

CLINICAL EXAMPLES: Clinical examples of the codes for E/M services are provided to assist in understanding the meaning of the descriptors and selecting the correct code. 

The same problem, when seen by different specialties, may involve different amounts of work. Therefore, the appropriate level of encounter should be reported using the descriptors rather than the examples.

INSTRUCTIONS FOR SELECTING A LEVEL OF E/M SERVICE

 Review the Reporting Instructions for the Selected Category or Subcategory: Most of the categories and many of the subcategories of service have special guidelines or instructions unique to that category or subcategory. Where these are indicted, eg, “Inpatient Hospital Care,” special instructions will be presented preceding the levels of E/M services.

 Review the Level of E/M Service Descriptors and Examples in the Selected Category or Subcategory: 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; 

• Time. 

The first three of these components (ie, history, examination and medical decision making) should be considered the key components in selecting the level of E/M services. An exception to this rule is in the case of visits which consist predominantly of counseling or coordination of care. (See instructions for selecting level of E/M Service).

The nature of the presenting problem and time are provided in some levels to assist the physician in determining the appropriate level of E/M service.

 Determine the Extent of History Obtained: The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of history that are defined as follows:

Problem Focused - Chief complaint; brief history of present illness or problem. 

Expanded Problem Focused - Chief complaint; brief history of present illness; problem pertinent system review. 

Detailed - Chief complaint; extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, and/or social history directly related to the patient’s problems.

Comprehensive - Chief complaint; extended history of present illness; review of systems that is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; complete past, family, and social history. 

The comprehensive history obtained as part of the preventive medicine E/M service is not problem-oriented and does not involve a chief complaint or present illness. It does, however, include a comprehensive system review and comprehensive or interval past, family, and social history as well as a comprehensive assessment/history of pertinent risk factors.