E/M codes are generic and are intended for use by all medical practitioners including nurse-practitioners, physicians and physician assistants. They can be used in both specialty care and primary care. All E/M codes can be used for reporting services. The decision on which E/M code to use is informed by which code describes most accurately the service the patient is to receive. The flexibility of E/M codes allows for easy and flexible reporting when service provided has more medical content or when more of coordination and counseling of care is given than psychotherapy (Codes and Documentation for Evaluation and Management Services).
The Creator of E/M Codes
E/M codes were created by the E/M Guidelines. The E/M Guidelines documents what is required for all E/M code documentations. The Centre for Medicare and Medicaid Services (CMS) together with the American Medical Association developed the E/M guidelines. So far, two versions of the guidelines have been released. The first one was released in 1995 while the second one was released in 1997. The E/M guidelines outline what is required for individual E/M codes given the extent of documentation of three significant components. Generally, E/M codes that attract the highest fees such as initial visits and consultations require more thorough documentation than the other codes that attract much lower fees such as hospital progress notes or visits made by an established client/patient (Physician-to-Physician E/M Compliance Solutions 2003).
Summarize the 3 key components of E/M documentation
Key Components
While selecting E/M services, the key components to pay attention to are Examination, Medical Decision Making and History. The three components are always captured in the descriptors for outpatient services, home services, domiciliary care services, nursing facility services, emergency department services, consultations, hospital inpatient services and hospital observation services (Kane, Reinertsen & Scottong, 2011).
History
The extent to which history is documented depends on the judgment of the physician as well as the nature of the problem or illness. There are different kinds of history and they include:
Problem-Focused
• Chief Complaint;
• A brief history of the problem or present illness
Expanded Problem-Focused
• Chief Complaint;
• A Brief history of the problem or present illness
• Problem-pertinent system review
Detailed
• Chief complaint
• A brief history of the problem or present illness
• Extended system review
• Pertinent social, family and past history
Comprehensive
• Chief complaint
• An extended history of the problem or present illness
• Complete system review
• A complete social, family and past history
Each kind of history detailed above covers some or all of the components below:
a) Chief Complaint -- it is a definite statement stating the symptom, condition, problem, diagnosis, return recommended by physician, or any other factors contributing to the encounter (Painter).
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A chief complaint has to be stated at every level for any kind of history to be qualified for.
b) History of Present Illness (HPI) -- it is a description made in a chronological order of the presenting problem or illness from the very first symptom or sign or from the initial encounter to the current one. HPI can be either brief or extended and the two are differentiated by the depth of detail involved in documentation. A brief one has one to three elements while an extended one can have four or more elements (1997 criteria only).
c) Past, Family and Social History (PFSH) -- past history covers the history of significant illnesses, injuries, hospitalizations, allergies, age appropriate immunization status and allergies. Family history has to do with a record of the state of health of parents, children, siblings and the causes of death of these members of the family. It also covers health complaints that are connected with the presenting illness. Social history has to do with marital status/living arrangements, employment status, professional history, drug use history, sexual history and other social factors that are relevant to the current situation (Evaluation and Management (E/M Services).
2. Physical Examination
The extent and nature of examination done and documented depends on the judgment of the clinician, the history of the patient as well as the nature and kind of the presenting problem. A physical examination can be an evaluation of just one body part to an evaluation of a multi-system or a thorough evaluation of an organ system.
a. Types of examinations
There are four kinds of examinations upon which E/M services are based upon:
• Problem Focused -- involves a limited evaluation of….....
Codes and Documentation for Evaluation and Management Services. Retrieved January 10, 2017, from https://www.cms.gov/Outreach-and.../eval-mgmt-serv-guide-ICN006764.pdf
Evaluation and Management (E/M) Services. Retrieved January 10, 2017, from http://ahc.buffalo.edu/docs/Compliance-E-M-Training-Guide.pdf
Kane, G., Reinertsen, L., & Sottong, E. (2011). Department of Health and Human Services Centers for Medicare & Medicaid Services.
Painter, F. THE 3 KEY COMPONENTS OF THE E/M GUIDELINES. Retrieved January 10, 2017, from http://www.chiro.org/LINKS/ABSTRACTS/Three_Key_Components.shtml
Physician-to-Physician E/M Compliance solutions (2003). Retrieved January 10, 2017, from http://emuniversity.com/Definitions.html
Rudman, W. J., Eberhardt, J. S., Pierce, W., & Hart-Hester, S. (2009). Healthcare fraud and abuse. Perspectives in Health Information Management/AHIMA, American Health Information Management Association, 6(Fall).
