by BC Advantage
November 29th, 2016
The CPT codes which describe provider-patient encounters are often referred to as "E/M codes." There are different E/M codes for different types of encounters such as office visits or hospital visit. There are different E/M codes for different types of encounters, such as office visits or hospital visits. Within each type of encounter, there are different levels of care. For example, the 99214 code may be used to charge for an office visit with an established patient. There are five levels of care for this type of encounter: 99211 - 99215.
The 99214 code is often called a "level 4" office visit because the code ends in a "4" and also because it is the fourth "level of care" for an established patient visit.
Each patient encounter should be carefully documented in the patient chart.
The documentation for E/M services is based on three "key" components, History, Physical Exam and Medical Decision Making. The key components are used to satisfy the documentation requirements for E/M coding.
The E/M key components can be thought of as the building blocks of documentation for all patient encounters. Some types of encounters require complete documentation of all three key components, while others require only two out of three.
HISTORY - is a narrative in the patient's own words which provides information about the clinical problems or symptoms being addressed during the encounter. As the history increases in intensity, so does the level of care. The history is composed of four building blocks.
1. Chief Complaint (CC) - A concise statement in the patient's own words that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. In an audit payment for services can be denied simply because the chart note did not include a chief complaint.
2. History of Present Illness (HPI) – 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.
- Modifying Factors
- Associated Signs and Symptoms
b. Extended HPI - According to the 1997 guidelines, at least four elements of the present HPI or the status of a least three chronic or inactive conditions.
3. Review of Systems (ROS) - An inventory of specific body systems discussed by the physician or medical assistant in the process of taking the history from the patient. The ROS is designed to bring out clinical symptoms which the patient may have overlooked or forgotten. In theory, the ROS may illuminate the diagnosis by bringing out information which the patient may not perceive as being important enough to mention to the physician.
- Constitutional (e.g., fever, weight loss)
- Ears, Nose, Mouth, Throat
- Integumentary (skin and/or breast)
- Past history
- Family history
- Social history
2. Expanded problem focused - A limited exam of the affected body area or organ system and other symptomatic or related organ system(s).
3. Detailed - An extended exam of the affected body area(s) and other symptomatic or related organ system(s).
4. Comprehensive - A general multisystem exam or a complete exam of a single organ system.
- The nature and number of clinical problems
- The amount and complexity of the data reviewed by the physician
- The risk of morbidity and mortality to the patient.
- Low Complexity
- Moderate Complexity
- High Complexity
Two versions have been released; the first in 1995 and the last in 1997.