AMA CPT® Assistant - 1991 Issue 4 (Winter)
Evaluation and Management (E/M) Codes (Winter 1991)
Winter 1991 pages 11-16 Evaluation and Management (E/M) Codes The purpose of this article is to provide an overview of the new evaluation and management (E/M) codes. The changes to the evaluation and management (E/M) codes (formerly called visits or levels of service codes) are probably the most significant changes to CPT that affect physicians reporting their services to third party payors. What follows are some general suggestions on how to use the new E/M codes as well as some observations on how these codes differ from the previous levels of service codes. It is essential that the general...
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Article Overview
This article explains the early CPT evaluation and management (E/M) code system and the broad guidance that accompanied its introduction for the 1992 code set. It is useful for readers who need historical context on E/M structure, category and subcategory organization, documentation concepts, and the kinds of reporting changes discussed for office, hospital, consultation, emergency, nursing facility, preventive medicine, case management, and critical care services.
Why This Topic Matters
The piece helps coders, compliance staff, educators, and practices understand the foundational changes that shaped modern E/M reporting and the accompanying guidance around selecting service levels, documenting care, and recognizing related code changes.
Article Sections
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Winter 1991 pages 11-16
Publication information for the article and its placement within the source issue.
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General Information
Introduces the new E/M code section and explains the broader shift in organization and approach compared with prior visit-based reporting.
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Guidelines
Summarizes the general and category-specific guidance that applies across the E/M section and explains its overall arrangement.
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Definitions
Reviews the major definition changes highlighted in the article, including patient status, concurrent care, counseling, presenting problem, and time-related concepts.
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Unlisted Service
Discusses the presence of unlisted E/M codes and the general expectation for reporting unusual or new services.
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Special Report
Addresses the use of special reports when reporting unlisted or atypical services.
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Modifiers
Covers the modifiers newly associated with E/M services and the global package in the CPT 1992 context.
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Instructions for Selecting a Level of E/M Service
Outlines the general process for choosing a level of E/M service using category selection, documentation review, and component assessment.
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Highlights from the Various Categories and Subcategories of E/M Services
Provides a broad tour of the major E/M service categories and the types of changes or guidance associated with each one.
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Summary
Recaps the key questions used to determine the appropriate E/M reporting category and level.
What You Will Learn
- How the new E/M section was organized in the 1992 CPT framework
- Which broad E/M service categories and subcategories were discussed
- What kinds of documentation concepts were emphasized for E/M reporting
- How time, counseling, coordination of care, and presenting problem were treated at a high level
- Which related modifiers and unlisted services were mentioned in connection with E/M reporting
Who Should Read This
- Professional medical coders
- Coding educators and auditors
- Physician practices
- Compliance and revenue cycle teams
- Health information management professionals
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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