PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)

There are three basic history areas required for a complete PFSH:

1. Past medical/psychiatric history: Illnesses, operations, injuries, treatments

2. Family history: Family medical history, events, hereditary illnesses 

3. Social history: Age-appropriate review of past and current activities 

The data elements of a textbook psychiatric history, listed below, are substantially more complete than the elements required to meet the threshold for a comprehensive or complete PFSH:

• Family history 

• Birth and upbringing 

• Milestones 

• Past medical history 

• Past psychiatric history 

• Educational history

• Vocational history 

• Religious background 

• Dating and marital history 

• Military history

• Legal history 

The two levels of PFSH are:

1. Pertinent, which is a review of the history areas directly related to the problem(s) identified in the HPI. The pertinent PFSH must document one item from any of the three history areas. In the following example, the patient’s past psychiatric history is reviewed as it relates to the current HPI:

• Patient has a history of a depressive episode 10 years ago successfully treated with Prozac. Episode lasted 3 months.

2. Complete. At least one specific item from two of the three basic history areas must be documented for a complete PFSH for the following categories of E/M services:

• Office or other outpatient services, established patient 

• Emergency department 

• Domiciliary care, established patient 

• Home care, established patient 

At least one specific item from each of the three basic history areas must be documented for the following categories of E/M services:

• Office or other outpatient services, new patient 

• Hospital observation services 

• Hospital inpatient services, initial care 

• Consultations 

• Comprehensive nursing facility assessments 

• Domiciliary care, new patient 

• Home care, new patient  

REVIEW OF SYSTEMS (ROS)

The review of systems is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following systems are recognized:

• Constitutional (e.g., temperature, weight, height, blood pressure) 

• Eyes 

• Ears, nose, mouth, throat 

• Cardiovascular 

• Respiratory

• Gastrointestinal 

• Genitourinary 

• Musculoskeletal 

• Integumentary (skin and/or breast) 

• Neurological 

• Psychiatric

• Endocrine 

• Hematologic/Lymphatic 

• Allergic/Immunologic

There are three levels of ROS:

1. Problem pertinent, which inquires about the system directly related to the problem identified in the HPI. In the following example, one system—psychiatric—is reviewed:

• CC: Depression.

• ROS: Positive for appetite loss and weight loss of 5 pounds (gastrointestinal/constitutional).

2. Extended, which inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. In the following example, two systems—constitutional and neurological— are reviewed:

• CC: Depression. 

• ROS: Patient reports a 5-lb weight loss over 3 weeks and problems sleeping, with early morning wakefulness

3. Complete, which inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems. In the following example, 10 signs and symptoms are reviewed:

Codes and Documentation for Evaluation and Management Services

Step 3: Review the Service Descriptors and the Requirements for the Key Components of the Selected E/M Service

Almost every category or subcategory of E/M service lists the required level of history, examination, or medical decision making for that particular code.

For example, for E/M code 99223 the service descriptor is “Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components” and the code requires 

• Comprehensive history 

• Comprehensive examination 

• Medical decision making of high complexity 

Step 4: Determine the Extent of Work Required in Obtaining the History

The extent of the history obtained is driven by clinical judgment and the nature of the presenting problem. Four levels of work are associated with history taking. They range from the simplest to the most complete and include the components listed in the sections that follow

The elements required for each type of history are depicted in Table 4–2. Note that each history type requires more information as you read down the left-hand column. For example, a problem-focused history requires the documentation of the chief complaint (CC) and a brief history of present illness (HPI), and a detailed history requires the documentation of a CC, an extended HPI, an extended review of systems (ROS), and a pertinent past, family, and/or social history (PFSH).

The extent of information gathered for a history is dependent on clinical judgment and the nature of the presenting problem. Documentation of patient history includes some or all of the following elements.

A. CHIEF COMPLAINT (CC) 

The chief complaint is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. It is usually stated in the patient’s own words. For example, “I am anxious, feel depressed, and am tired all the time.”

B. HISTORY OF PRESENT ILLNESS (HPI)

The history of present illness is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:

• Location (e.g., feeling depressed) 

• Quality (e.g., hopeless, helpless, worried) 

• Severity (e.g., 8 on a scale of 1 to 10) 

• Duration (e.g., it started 2 weeks ago)

• Timing (e.g., worse in the morning) 

• Context (e.g., fired from job) 

• Modifying factors (e.g., feels better with people around) 

• Associated signs and symptoms (e.g., loss of appetite, loss of weight, loss of sexual interest) 

There are two types of HPIs, brief and extended:

1. Brief includes documentation of one to three HPI elements. In the following example, three HPI elements—location, severity, and duration—are documented: 

• CC: Patient complains of depression.

• Brief HPI: Patient complains of feeling severely depressed for the past 2 weeks.

SELECTING THE LEVEL OF E/M SERVICE

The following are step-by-step instructions that guide you through the code selection process when providing services defined by E/M codes. Code selection is made based on the work performed.

Step 1: Select the Category and Subcategory of E/M Service

Step 2: Review the Descriptors and Reporting Instructions for the E/M Service Selected

Most of the categories and many of the subcategories of E/M services have special guidelines or instructions governing the use of the codes. For example, under the description of initial hospital care for a new or established patient, the CPT manual indicates that the inpatient care level of service reported by the admitting physician should include the services related to the admission that he or she provided in other sites of service as well as in the inpatient setting. E/M services that are provided on the same date in sites other than the hospital and that are related to the admission should not be reported separately

Examples of Descriptors for CPT Codes Used Most Frequently by Psychiatrists 

99221—Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:

• A detailed or comprehensive history 

• A detailed or comprehensive examination 

• Medical decision making that is straightforward or of low complexity 

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. 

Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.

Nursing Facility Services

INITIAL NURSING FACILITY CARE

99304—The three following components are required: 

• Detailed or comprehensive history 

• Detailed or comprehensive examination 

• Medical decision making that is straightforward or of low complexity 

Problem(s) requiring admission: Low severity 

Typical time: 25 minutes with patient and/or family or caregiver 

99305—The three following components are required:

 • Comprehensive history 

 • Comprehensive examination 

 • Medical decision making of moderate complexity 

Problem(s) requiring admission: Moderate severity 

Typical time: 35 minutes with patient and/or family or caregiver

 99306—The three following components are required: 

• Comprehensive history

• Comprehensive examination 

• Medical decision making of high complexity 

Problem(s) requiring admission: High severity 

Typical time: 45 minutes with patient and/or family or caregiver

SUBSEQUENT NURSING FACILITY CARE 

99307—Two of the three following components are required: 

• Problem-focused interval history 

• Problem-focused examination 

• Medical decision making that is straightforward 

Presenting problem(s): Patient usually stable, recovering, or improving 

Typical time: 10 minutes with patient and/or family or caregiver 

99308—Two of the three following components are required: 

• Expanded problem-focused interval history 

• Expanded problem-focused examination 

• Medical decision making of low complexity 

Presenting problem(s): Patient usually responding inadequately to therapy or has developed a minor complication 

Typical time: 15 minutes with patient and/or family or caregiver 

INPATIENT CONSULTATIONS

99251—The three following components are required:

 • Problem-focused history

 • Problem-focused examination 

• Medical decision making that is straightforward 

Presenting problem(s): Self-limited or minor 

Typical time: 20 minutes at the bedside or on the patient’s floor or unit

99252—The three following components are required: 

• Expanded problem-focused history 

• Expanded problem-focused examination 

• Medical decision making that is straightforward

 Presenting problem(s): Low severity 

Typical time: 40 minutes at the bedside or on the patient’s floor or unit 

99253—The three following components are required:

 • Detailed history 

 • Detailed examination

 • Medical decision making of low complexity

 Presenting problem(s): Moderate severity 

Typical time: 55 minutes at the bedside or on the patient’s floor or unit

 99254—The three following components are required: 

• Comprehensive history 

• Comprehensive examination 

• Medical decision making of moderate complexity 

Presenting problem(s): Moderate to high severity 

Typical time: 80 minutes at the bedside or on the patient’s floor or unit 

99255—The three following components are required: 

• Comprehensive history

• Comprehensive examination

• Medical decision making of moderate complexity 

Presenting problem(s): Moderate to high severity 

Typical time: 110 minutes at the bedside or on the patient’s floor or unit 

Emergency Department Services

No distinction is made between new and established patients in this setting. There are no typical times provided for emergency E/M services

99281—The three following components are required: 

• Problem-focused history 

• Problem-focused examination 

• Medical decision making that is straightforward

 Presenting problem(s): Self-limited or minor 

HOSPITAL DISCHARGE SERVICES

99238—Time: 30 minutes or less 

99239—Time: More than 30 minutes

Consultations

Medicare no longer pays for the consultation codes. When coding for Medicare or for commercial carriers that have followed Medicare’s lead, 90801 may be used for both inpatient and outpatient consults. Psychiatrists who choose to use E/M codes to report outpatient consults should use the outpatient new patient codes (99201–99205). For inpatient consults, the codes to use are hospital inpatient services, initial hospital care for new or established patients (99221– 99223). For consults in nursing homes, initial nursing facility care codes should be used (99304–99306); if the consult is of low complexity, the subsequent nursing facility codes may be used (99307–99310). As with all E/M codes, the selection of the specific code is based on the complexity of the case and the amount of work required. Medicare has created a new modifier, A1, to denote the admitting physician so that more than one physician may use the initial hospital care codes.

OFFICE OR OTHER OUTPATIENT CONSULTATIONS 

99241—The three following components are required: 

• Problem-focused history

• Problem-focused examination 

• Medical decision making that is straightforward 

Presenting problem(s): Self-limited or minor 

Typical time: 15 minutes face-to-face with patient and/or family

 99242—The three following components are required: 

• Expanded problem-focused history 

• Expanded problem-focused examination 

• Medical decision making that is straightforward 

Presenting problem(s): Low severity 

Typical time: 30 minutes face-to-face with patient and/or family

 99243—The three following components are required:

 • Detailed history 

• Detailed examination 

 • Medical decision making of low complexity 

Presenting problem(s): Moderate severity 

Typical time: 40 minutes face-to-face with patient and/or family 

99244—The three following components are required: 

• Comprehensive history 

• Comprehensive examination 

• Medical decision making of moderate complexity 

Hospital Inpatient Services

Services provided in a partial hospitalization setting would also use these codes

INITIAL HOSPITAL CARE FOR NEW OR ESTABLISHED PATIENT

99221—The three following components are required: 

• Detailed or comprehensive history 

• Detailed or comprehensive examination

• Medical decision making that is straightforward or of low complexity 

Presenting problem(s): Low severity 

Typical time: 30 minutes at the bedside or on the patient’s floor or unit 

99222—The three following components are required:

• Comprehensive history 

• Comprehensive examination 

• Medical decision making of moderate complexity 

Presenting problem(s): Moderate severity

Typical time: 50 minutes at the bedside or on the patient’s floor or unit 

99223—The three following components are required: 

• Comprehensive history 

• Comprehensive examination 

• Medical decision making of high complexity 

Presenting problem(s): High severity 

Typical time: 70 minutes at the bedside or on the patient’s floor or unit

ESTABLISHED PATIENT

99211—This code is used for a service that may not require the presence of a physician. Presenting problems are minimal, and 5 minutes is the typical time that would be spent performing or supervising these services.

99212—Two of the three following components are required:

• Problem-focused history 

• Problem-focused examination 

• Medical decision making that is straightforward 

Presenting problem(s): Self-limited or minor 

Typical time: 10 minutes face-to-face with patient and/or family

99213—Two of the three following components are required:

• Expanded problem-focused history

• Expanded problem-focused examination 

• Medical decision making of low complexity

Presenting problem(s): Low to moderate severity

Typical time: 15 minutes face-to-face with patient and/or family 

99214—Two of the three following components are required: 

• Detailed history 

• Detailed examination 

• Medical decision making of moderate complexity 

Presenting problem(s): Moderate to high severity 

Typical time: 25 minutes face-to-face with patient and/or family

99215—Two of the three following components are required:

• Comprehensive history

• Comprehensive examination 

• Medical decision making of high complexity

Presenting problem(s): Moderate to high severity 

Typical time: 40 minutes face-to-face with patient and/or family

Codes and Documentation for Evaluation and Management Services

EVALUATION AND MANAGEMENT CODES MOST LIKELY TO BE USED BY PSYCHIATRISTS AND OTHER APPROPRIATELY LICENSED MENTAL HEALTH PROFESSIONALS 

It is vital to read the explanatory notes in the CPT manual for an accurate understanding of when each of these codes should be used.

Note: For each of the following codes 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.” As stated earlier, 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

Office or Other Outpatient Services

NEW PATIENT

99201—The three following components are required:

• Problem-focused history

• Problem-focused examination

• Medical decision making that is straightforward 

Presenting problem(s): Self-limited or minor Typical time: 10 minutes face-to-face with patient and/or family

99202—The three following components are required:

• Expanded problem-focused history

• Expanded problem-focused examination 

• Medical decision making that is straightforward

Presenting problem(s): Low to moderate severity Typical time: 20 minutes face-to-face with patient and/or family

99203—The three following components are required:

• Detailed history 

• Detailed examination

• Medical decision making of low complexity

Presenting problem(s): Moderate severity 

Typical time: 30 minutes face-to-face with patient and/or family

TIME

For the purpose of selecting the level of service, time has two definitions.

1. For office and other outpatient visits and office consultations, intraservice time (time spent by the clinician providing services with the patient and/or family present) is defined as face-to-face time. Pre- and post-encounter time (non-face-to-face time) is not included in the average times listed under each level of service for either office or outpatient consultative services. The work associated with pre- and post-encounter time has been calculated into the total work effort provided by the physician for that service

2. Time spent providing inpatient and nursing facility services is defined as unit/ floor time. Unit/floor time includes all work provided to the patient while the psychiatrist is on the unit. This includes the following:

• Direct patient contact (face-to-face)

• Review of charts

• Writing of orders

• Writing of progress notes

• Reviewing test results

• Meeting with the treatment team

• Telephone call

• Meeting with the family or other caregivers

• Patient and family education 

Work completed before and after direct patient contact and presence on the unit/floor, such as reviewing X-rays in another part of the hospital, has been included in the calculation of the total work provided by the physician for that service. Unit/floor time may be used to select the level of inpatient services by matching the total unit/floor time to the average times listed for each level of inpatient service. For instance:

99221 

Descriptor: Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: 

• A detailed or comprehensive history 

• A detailed or comprehensive examination 

• Medical decision making that is straightforward or of low complexity

REVIEW OF SYSTEMS (ROS)

The review of systems is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following systems are recognized:

• Constitutional (e.g., temperature, weight, height, blood pressure) 

• Eyes 

• Ears, nose, mouth, throat 

• Cardiovascular 

• Respiratory 

• Gastrointestinal

• Genitourinary

• Musculoskeletal 

• Integumentary (skin and/or breast) 

• Neurological

• Psychiatric 

• Endocrine 

• Hematologic/Lymphatic 

• Allergic/Immunologic

There are three levels of ROS:

1. Problem pertinent, which inquires about the system directly related to the problem identified in the HPI. In the following example, one system—psychiatric—is reviewed: 

• CC: Depression. 

• ROS: Positive for appetite loss and weight loss of 5 pounds (gastrointestinal/constitutional).

2. Extended, which inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. In the following example, two systems—constitutional and neurological— are reviewed:

• CC: Depression. 

• ROS: Patient reports a 5-lb weight loss over 3 weeks and problems sleeping, with early morning wakefulness.

3. Complete, which inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems. In the following example, 10 signs and symptoms are reviewed:

• CC: Patient complains of depression. 

• ROS:

a. Constitutional: Weight loss of 5 lb over 3 weeks 

b. Eyes: No complaints 

c. Ear, nose, mouth, throat: No complaints

d. Cardiovascular: No complaints

e. Respiratory: No complaints 

f. Gastrointestinal: Appetite loss 

g. Urinary: No complaints 

h. Skin: No complaints 

i. Neurological: Trouble falling asleep, early morning awakening 

j. Psychiatric: Depression and loss of sexual interest

PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)

There are three basic history areas required for a complete PFSH: 

1. Past medical/psychiatric history: Illnesses, operations, injuries, treatments

2. Family history: Family medical history, events, hereditary illnesses 

3. Social history: Age-appropriate review of past and current activities 

The data elements of a textbook psychiatric history, listed below, are substantially more complete than the elements required to meet the threshold for a comprehensive or complete PFSH:

• Family history 

• Birth and upbringing 

• Milestones 

• Past medical history

• Past psychiatric history

• Educational history 

• Vocational history 

• Religious background 

• Dating and marital history

• Military history 

• Legal history 

The two levels of PFSH are:

1. Pertinent, which is a review of the history areas directly related to the problem(s) identified in the HPI. The pertinent PFSH must document one item from any of the three history areas. In the following example, the patient’s past psychiatric history is reviewed as it relates to the current HPI: 

• Patient has a history of a depressive episode 10 years ago successfully treated with Prozac. Episode lasted 3 months.

2. Complete. At least one specific item from two of the three basic history areas must be documented for a complete PFSH for the following categories of E/M services:

• Office or other outpatient services, established patient 

• Emergency department 

• Domiciliary care, established patient 

• Home care, established patient 

At least one specific item from each of the three basic history areas must be documented for the following categories of E/M services:

• Office or other outpatient services, new patient 

• Hospital observation services 

• Hospital inpatient services, initial care 

• Consultations 

• Comprehensive nursing facility assessments

• Domiciliary care, new patient 

• Home care, new patient

HISTORY OF PRESENT ILLNESS (HPI)

Step 3: Review the Service Descriptors and the Requirements for the Key Components of the Selected E/M Service

Almost every category or subcategory of E/M service lists the required level of history, examination, or medical decision making for that particular code

For example, for E/M code 99223 the service descriptor is “Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components” and the code requires

• Comprehensive history 

• Comprehensive examination 

• Medical decision making of high complexity 

Step 4: Determine the Extent of Work Required in Obtaining the History 

The extent of the history obtained is driven by clinical judgment and the nature of the presenting problem. Four levels of work are associated with history taking. They range from the simplest to the most complete and include the components listed in the sections that follow. 

The elements required for each type of history are depicted in Table 4–2. Note that each history type requires more information as you read down the left-hand column. For example, a problem-focused history requires the documentation of the chief complaint (CC) and a brief history of present illness (HPI), and a detailed history requires the documentation of a CC, an extended HPI, an extended review of systems (ROS), and a pertinent past, family, and/or social history (PFSH). 

The extent of information gathered for a history is dependent on clinical judgment and the nature of the presenting problem. Documentation of patient history includes some or all of the following elements.

A. CHIEF COMPLAINT (CC)

 The chief complaint is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. It is usually stated in the patient’s own words. For example, “I am anxious, feel depressed, and am tired all the time.” 

B. HISTORY OF PRESENT ILLNESS (HPI) 

The history of present illness is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:

• Location (e.g., feeling depressed) 

• Quality (e.g., hopeless, helpless, worried) 

• Severity (e.g., 8 on a scale of 1 to 10) 

• Duration (e.g., it started 2 weeks ago)

• Timing (e.g., worse in the morning) 

• Context (e.g., fired from job)

 • Modifying factors (e.g., feels better with people around) 

• Associated signs and symptoms (e.g., loss of appetite, loss of weight, loss of sexual interest) 

There are two types of HPIs, brief and extended:

1. Brief includes documentation of one to three HPI elements. In the following example, three HPI elements—location, severity, and duration—are documented: 

• CC: Patient complains of depression. 

• Brief HPI: Patient complains of feeling severely depressed for the past 2 weeks

2. Extended includes documentation of at least four HPI elements or the status of at least three chronic or inactive conditions. In the following example, five HPI elements—location, severity, duration, context, and modifying factors—are documented:

 • CC: Patient complains of depression. 

• Extended HPI: Patient complains of feelings of depression for the past 2 weeks. Lost his job 3 weeks ago. Is worried about finances. Trouble sleeping, loss of appetite, and loss of sexual interest. Rates depressive feelings as 8/10. 

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.