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Components of E-M Visit

Components of E-M Visit

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Published by CRB
Learned in Medical Insurance Billing & Coding class!! Components of E/M Visit
Learned in Medical Insurance Billing & Coding class!! Components of E/M Visit

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Published by: CRB on Oct 28, 2009
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Lecture: The “Components” of the E/M Visit6 Keys for Accurate EM CodingKey #1:
History (HX)
 There are three components of that should be documented for patient history. Theyare 1) history of present illness (HPI), which includes the chief compliant (CC), 2)review of (organ) systems (ROS), and 3) review of past medical, family and socialhistory (PFSH). Generally, the medical assistant or nurse will document the patient’sCC and HPI. The CC, according to CMS, should be “
a concise statement describingthe symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter 
”. Most physician offices use a history formtemplate, and the patient fills in the blanks for the review of systems.For all patients, all three components of the history, e.g., HPI, ROS and PFSH arerequired to be documented for a “complete” history, or 2 components for a“pertinent” history.
Key #2:
Physical Exam (PE)
 There are two sets of Official Coding Guidelines published by CMS that particularlyaffect the physical exam component of EM. They are the 1995 Evaluation andManagement Documentation Guidelines and the 1997 Evaluation and ManagementDocumentation Guidelines. See Chart 2: 1995 and 1997 EM Physical ExamGuidelines: Source Original Chart, Criteria from CMS Guidelines To determine the level of physical exam performed using the 1995 guidelines, thecoder should count the number of organ systems or body areas examined anddocumented by the physician. To determine the EM level of the physical exam usingthe 1997 guidelines, the coder should count “elements” of a particular organ systemexamined. The 1995 guidelines are generally used by primary care physicians (PCPs), becausethey tend to look at more organ systems in their examination of the patient.Specialty physicians tend to use the 1997 guidelines because they tend to examineone or fewer organ systems and focus on a single organ system. For example, anophthalmologist obviously exams eyes; therefore, they will get credit for the“elements” that they exam during the eye exam. The coder will count the examelements that the physician has documented and then choose the level of exambased on those elements. For example, if the ophthalmologist does all 12examination bullet points in Illustration 2, then they will get credit for a “detailed”examination. In order for the ophthalmologists to get credit for a comprehensivephysical exam, they would have to examine additional organ systems in addition tothe eye. In total, the 1997 guidelines define twelve categories of single systemexaminations (SSE), including psychiatry, neurology, dermatology, gastrointestinal,cardiology, respiratory, musculoskeletal, genitourinary, ear nose and throat (ENT),and hematologic/lymphatic/immunologic.
Key #3:
Medical Decision Making (MDM)
Next is determining the level of the physician’s medical decision making (MDM). TheMDM refers to the level of risk and difficulty involved in the diagnosing, treatment,and medical planning that is involved in an EM visit. The MDM may be straightforward, low complexity, moderate complexity or high complexity. See Chart 3:Decision Making (RISK table)SF: Straight Forward
Minimal 1Minimal 1Minimal 1
LC: Low Complexity
Limited 2Limited 2Low
MC: ModerateComplexity
Multiple 3Multiple 3Moderate
HC: High Complexity
Extensive >4Extensive >4High
Key #4:
 Time is a “time” component of the EM codes. However, time does not takeprecedence of appropriate documentation of the history, physical and medicaldecision making. If a physician documents a comprehensive EM service is less thanthe time allotted, he still may charge for the comprehensive service. Similarly, if thephysician takes more time than allotted to document the same comprehensive visit,he may still only charge according to the document elements of the visit. The onlyexception to this is with counseling and coordination of care. Some E/M is timedependant like critical care and in this specific case the exact time spent must bedocumented. See Critical care section below.
Key #5:
Counseling, and/or Coordination of Care
When counseling and/or coordination of care comprises more than 50% of the timespent during an EM visit, then time may be considered the key or controlling factor toqualify for a particular level of E/M service. However, several criteria must be met.First, the physician’s “time” must be spent “face–to-face” with either the patient orthe patient’s family. For inpatient, if the physician is just on the hospital unit floorcharting and doing other tasks, which are not face-to-face with the patient orpatient’s family, then this time does not count towards the EM service. Second, thecounseling must be fully documented, e.g., what was said, done, planned and soforth. Third, time should be documented. If this is a time-driven EM, then start timeand stop times for the face-to-face encounter should be documented in the PHR.
Key #6 Choosing an EM Level
Now we will summarize the documented history, physical exam and medical decisionmaking and choose a level of EM. Here are several scenarios of EM for new andestablished patients. Remember when choosing an level, a new EM service requiresall 3 components to be at the highest level in order to choose that particular code,versus an established EM service only requires 2 out of 3 to choose a level.

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