Evaluation and management (E/M) service tips and tools

Key point to remember

As stated in the Centers for Medicare & Medicaid Services (CMS) Internet-only Manuals (IOM) 100-04, Chapter 12, Section 30.6.1:

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

The key components (elements of service) of evaluation & management (E/M) services are:

1. History

2. Examination

3. Medical decision-making

When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.

Tips pertaining to different types of E/M services can be located by accessing the links in the table below:

CPT code range                                   Type of E/M service

99201-99205                                    Office or other outpatient E/M services for new patients

99211-99215                                    Office or other outpatient E/M services for established patients

99221-99223                                    Initial hospital care E/M services

99231-99233                                    Subsequent hospital care E/M services

96150-96152, G0425-G0427           Telehealth Services Medicare Payment for Telehealth services