decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Evaluation and Management Services / Levels of EM services
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Article Overview
This article explains the general framework for evaluation and management service levels, including how services are categorized, the major components used in level selection, and how time is considered in different settings. It is useful for coders, auditors, and clinicians who need a high-level understanding of E/M documentation and level determination concepts.
Why This Topic Matters
Understanding E/M level structure helps readers recognize what factors drive service classification across office, outpatient, inpatient, observation, consultation, and facility-based encounters. The article provides background needed to interpret E/M guidance without focusing on a single specialty or one code family.
Article Sections
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Overview of E/M service levels
Introduces the concept of service levels within evaluation and management coding and explains that level structure varies by service type, place of service, and patient condition.
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Components used to describe E/M services
Summarizes the broad elements used to characterize E/M services and distinguishes the key elements from contributory factors.
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Time in office and outpatient services
Describes how time is generally considered for office and other outpatient encounters and distinguishes it from non-face-to-face work related to the visit.
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Time in inpatient and facility-based services
Explains how time is generally measured for hospital observation, inpatient care, consultations, nursing facility services, and similar settings.
What You Will Learn
- How evaluation and management service levels are organized
- Which broad components are used to describe E/M services
- How time is treated differently in office/outpatient settings and inpatient or facility-based settings
- Which encounter types use face-to-face time versus unit/floor time concepts
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation staff
- Revenue cycle professionals
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