AMA CPT® Assistant - 2009 Issue 12 (December)
Evaluation and Management (E/M) Services (December 2009)
December 2009 page 9 Bonus Feature:Evaluation and Management (E/M) Services Question: When choosing a new or established outpatient E/M service code, is it necessary to perform all three key components in order to qualify for reporting? Patty Shol, CPC Answer: History, examination, and medical decision making are considered the key components in selecting a level of E/M services. As a general rule, these are the first components to be considered when determining the level of E/M service to report. As indicated in the descriptor language of the new and established outpatient E/M service codes 99201-99205, each of the three...
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Article Overview
This article addresses a basic evaluation and management topic from CPT Assistant and is aimed at coders, billers, and other revenue cycle professionals working with outpatient E/M services. It discusses how the key components are considered in selecting service levels, notes differences between new and established patient visits, and points readers to CPT guidance on time-based considerations and exceptions. The piece is useful for anyone needing a quick refresher on how the outpatient E/M framework is presented in the CPT codebook.
Why This Topic Matters
Outpatient E/M coding is a frequent source of documentation and level-selection questions, so even a short clarification can help readers understand the scope of the CPT guidance they should review in full.
Article Sections
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Bonus Feature: Evaluation and Management (E/M) Services
A short Q&A discussing outpatient E/M service selection concepts for new and established patients. It references general CPT guidance and mentions a time-related exception category.
What You Will Learn
- How outpatient E/M service levels are generally considered in CPT
- The difference in general component expectations for new versus established patient visits
- Where to look in CPT guidance for broader E/M service selection considerations
- The type of exception discussed for counseling or coordination-of-care visits
Who Should Read This
- Medical coders
- Billing specialists
- Revenue cycle staff
- Compliance professionals
- Clinical documentation staff
Codes Discussed
Code Ranges Discussed
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