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.

DEFINITIONS OF COMMONLY USED TERMS

 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.