Evaluation And Management

Out-Patient Coding
 Evaluation And Management

Evaluation and Management is a medical service in which the

provider completely evaluates patients physical, mental health
related conditions (Diseases or symptoms, history of disease) and
treats the conditions with management options (Prescriptions,
surgery, counselling).
 E&M Out-Patient Coding
Out-Patient visits are the medical services in which the provider evaluates the patient with out the
admission. Usually out-patient services are called as ‘Office Visits’.
E&M out patient coding consist of the following

Out-Patient
Serv ices

Out-Patient
Consultations Preventive
Office Visits
Medicines
(99241-99245)

Established
New Patient
Patient
(99201-99205)
(99211-99215)
 New Patient V/s Established Patient

New Patient: A new patient is one who has not received any professional services ( those face-
to-face services rendered by physicians and other qualified health care professionals who may
report evaluation and management services reported by a specific CPT code(s)) from the
physician/qualified health care professional or another physician/qualified health care
professional of the exact same specialty and subspecialty who belongs to the same group
practice, within the past three years.

Established Patient: An established patient is one who has received professional services
from the physician/qualified health care professional or another physician/ qualified health
care professional of the exact same specialty and subspecialty who belongs to the same group
practice, within the past three years.
 Consultation Services

Consultations is a service in which one provider renders the services to a patient on request
of another provider. To code consultations it requires of Referral physician, rendering
physician, Record should be documented.

Consultation

Referral Rendering Report

Key Components Of E&M

Key Components

[Link]

[Link]

[Link] Decision Making

Contributory Elements

Counseling

Coordination of care

Nature of presenting problem (illness)

Time
 History

Chief Complaint: Reason for the encounter is called as Chief Complaint. Every E&M
service consists of chief complaint except ‘Preventive Medicine services.

History: History consists of the following Elements. To calculate the level of history, it is necessary
to understand these elements.

HPI
History ROS
PFSH
 History Of Present Illness

History of present Illness: The HPI is a chronological description of the development of the
patient’s present illness from the first sign or symptom, or from the previous encounter, to
the present. The HPI must be documented by the provider. HPI is a patient statement.
There are eight elements of HPI.

1. Location: The anatomical place, position, or site of the chief complaint. For example:
ear pain, RUQ abdominal pain, cut foot.

2. Quality: Characteristics about the problem, such as how it looks or feels. For example:
green phlegm, itchy ear, metallic taste, throbbing pain, whistling sound.

3. Severity: A degree or measurement of how bad it is. For example: improved, extreme
pain, feeling better, intolerable pain. In some cases, the patient may rank the pain on a
scale of one to ten.
 History

4. Duration: How long the complaint has been occurring, or the time when the complaint first occurred.
For example: it occurred in childhood; He noticed it two weeks ago; For several years.

5. Timing: A measurement of when or at what frequency they noticed the complaint. For example:
intermittent or constant; it comes in the morning; lasts for five minutes, and then goes away.

6. Context: What the patient was doing, their environmental factors, the circumstances surrounding the
complaint. For example: while sleeping; in a motor vehicle accident

7. Modifying Factors: Anything that makes the problem better or worse. For example: improved with
Tylenol; worse when standing

8. Associated Signs and Symptoms: Associated secondary complaints. For example: the patient has a sore
throat and runny nose; the patient has abdominal pain but no nausea or vomiting; the patient has a
fever and is pulling at her ears.
Types of HPI:

Brief HPI: 1-3 HPI elements should be documented.

Extended HPI: 4 or 4+ Elements should be documented or status of 3 chronic problems

Example for HPI:

Patient complains of chest pain (location), which began three hours ago (duration). Pain has
been off and on since that time with each episode lasting two to three minutes (timing). The
pain is described as “crushing” (quality) and at times is rated as an eight on a scale of one to
ten (severity). The pain occurs with minimal exertion (context) and is associated with nausea
and shortness of breath (associated signs and symptoms). The pain was relieved with
sublingual NTG in the ambulance (modifying factors).

ROS:Review of systems is an investigational process in which the provider asks series of questions about
the body systems and patient answers. Here physician does not perform any examination. Patient respond
as positive or negative about the system can be considered as one 1 ROS.
There are 14 systems for ROS
There are 3 types of ROS
[Link]
[Link] [Link] Pertenent: only 1 ROS related to chief complaint
[Link], Nose, and Throat
[Link] 2. Extended ROS: 2-9 ROS
[Link]
[Link] [Link] ROS: 10+ ROS
[Link]
[Link] Alert: Some times we have extract ROS from HPI. But we should not
[Link] consider one symptom for both HPI & ROS. IF we pull that is called as
[Link] double dipping which should not be done.
11.0Psychiatric
[Link] Note for Complete ROS: If documentation of at least two ROS and
[Link]/Lymphatic the statement of ‘’all the remaining systems are nagative’’ can be
[Link]/Immunologic considered as complete ROS.
PFSH: Past Medical, Family, Social History

Past Medical History: Past history medical history of patient will be evaluated here.
Example: History of kidney stone.

Family History: Family history of patient will be evaluated here.

Example: Patient’s mother has breast cancer

Social History: Here life style activities will be evaluated.

Example: Patient is smoker, He works in factory.

Two types of PFSH.

Pertinent PFSH: any one of three histories should be documented

Complete History: 2 for Established patient, 3 for New Patient.

 Calculation of History level

Calculation of History: After the collection of HPI, ROS, PFSH we have to calculate History as
follows.
4 Levels of History History calculation Table (3/3 elements should be satisfied)

[Link] Focused HPI 1-3 elements 1-3 elements 4 or4 + 4 or4 +

elements elements
[Link] Problem Focused ROS N/A 1 2-9 ROS 10+
PFSH N/A N/A 1 2 or 3
[Link]
Level PF EPF Detailed Comprehensive
[Link]
Example for calculation of History: If medical record supports HPI Brief 3,
Extended ROS (7 ROS), PFSH is documented 1 the level history will be EPF because 3/3
elements are satisfied in EPF column

HPI 1-3 elements 1-3 elements 4 or4 + elements 4 or4 + elements

ROS N/A 1 2-9 ROS 10+

PFSH N/A N/A 1 2 or 3

Level PF EPF Detailed Comprehensive

 Examination
Examination: This is physical examination by the provider. Here the provider will examine
total 12 organs systems of the body. The total body organ systems are as follows.

Problem Focused Limited to affected body area or organ system (one

body area or system related to problem)
2-7 body organ systems with limited examination
Expanded Problem focused

Detailed 2-7 body organ systems with detailed examination

Comprehensive Examination of 8 organ systems or complete exam of

a single organ system.
 Medical Decision Making

MDM: is one of the Key components of E&M. In Calculation of E&M we have to consider
different parameters. We have to consider the following the tables for calculation of MDM.

Number of Diagnosis or Treatment Options

A B C B*C=D
Problems Status Number Points Result
Self-limited or Minor (stable, improved or worsening 1
Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening 2
New problem (to examiner); no additional workup planned 3
New prob (to examiner); add workup planned 4
Total
Table B:
Amount and/or Complexity of Data Reviewed

Reviewed Data Points

Review and/or order of clinical lab tests 1
Review and/or order of tests in the radiology section of CPT 1
Review and/or order of tests in the medicine section of CPT 1
Discussion of test results with performing physician 1
Decision to obtain old records and/or obtain history from someone other 1
than patient
Review and summarization of old records and/or obtaining history form 2
someone other than patient and/or discussion of case with another
health care provider
Independent visualization of image, tracing or specimen itself (not 2
simply review of report)
Total
 Risk Table: (C)
Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordere Management Options Selected

1. One self-limited or minor problem, e.g., • Laboratory tests requiring venipuncture • • Rest

Minimal cold insect bite, tinea corporis Chest X-rays • EKG/ EEG • Urinalysis •
Ultrasound, e.g., echo • KOH prep
• Gargles
• Elastic bandages
•Superficial dressings

• Two or more self-limited or minor • Physiologic tests not under stress, e.g., • Over-the-Counter drugs

Low problems
• One stable chronic illness, e.g., well
controlled hypertension or noninsulin
pulmonary function tests Noncardiovascular
imaging studies with contrast, e.g., barium
enema
• Minor surgery with no identified risk
factors
• Physical therapy
dependent diabetes, cataract, BPH • Superficial needle biopsies • Clinical • Occupational therapy
• Acute uncomplicated illness or injury, laboratory tests requiring arterial puncture • IV fluids without additives
e.g., cystitis, allergic rhinitis, simple sprain • Skin biopsies

• One or more chronic illness with mild • Physiologic tests under stress, e.g., • Minor surgery with identified risk factors •

Moderate exacerbation, progression, or side effects of

treatment • Two or more stable chronic
illnesses • Undiagnosed new problem with
cardiac stress test, fetal contraction stress
test • Diagnostic endoscopies with no
identified risk factors • Deep needle or
Elective major surgery (open, percutaneous
or endoscopic with no identified risk factors)
• Prescription drug management
uncertain prognosis, e.g., lump in breast • incisional biopsy • Cardiovascular imaging (continuation & new prescription) •
Acute illness with systemic symptoms, e.g., studies with contrast and no identified risk Therapeutic nuclear medicine • IV fluids
pyelonephritis, pneumonitis, colitis • Acute factors, e.g., arteriogram cardiac catheter • with additives • Closed treatment of
complicated injury, e.g., head injury with Obtain fluid from body cavity, e.g., lumbar fracture or dislocation without manipulation
brief loss of consciousness puncture, thoracentesis, culdocentesis
• One or more chronic illnesses with severe • Cardiovascular imaging studies with • Elective major surgery (open,

High exacerbation, progression, or side effects of

treatment • Acute or chronic illnesses or
injuries that may pose a threat to life or
contrast with identified risk factors
• Cardiac electrophysiological tests
• Diagnostic endoscopies with identified
percutaneous or endoscopic with identified
risk factors)
• Emergency major surgery (open,
bodily function, e.g., multiple trauma, risk factors percutaneous or endoscopic)
acute MI, pulmonary embolus, severe • Discography • Parental controlled substances
respiratory distress, progressive severe • Drug therapy requiring intensive
rheumatoid arthritis, psychiatric illness with monitoring for toxicity
potential threat to self or others, • Decision not to resuscitate or to de-
peritonitis, acute renal failure • An abrupt escalate care because of poor prognosis
change in neurologic status, e.g., seizure,
TIA, weakness or sensory loss
Calculation Of MDM:
By using Table A,B,C we can calculate MDM , 2/3 Elements should be satisfied . There are four
levels MDM as Follows.

[Link] Forward MDM

[Link]
[Link] Complexity
[Link] Complexity
MDM Calculation Table
A Number diagnoses or 1 2 3 * 4
treatment options
B Amount and Complexity 1 2 3 * 4
of Data
C Highest Risk Minimal Low * Moderate High
MDM Level Straight Low Complexity Moderate High
Forward Complexity Complexity

Example: If Number of presenting problems gives 3 (Points Table A), Data points reviewed is 3
points (Table C), If OTC drugs are given (Table C)
The MDM Will be Moderate Complexity as 2/3 elements are satisfied.
 Level Of E&M for New Patient/OP-Consultaion(3/3)

There are five levels of E&M service for New Patient/ OP-Consultations.
Table For New Patient/ OP-Consultaions
New Patient Consultation codes
1.99201 1.99241 History PF EPF * Detailed Comprehensive Comprehensive

2.99202 2.99242 Exam PF EPF Detailed * Comprehensive Comprehensive

3.99203 3.99243
4.99204 4.99244 MDM SF SF Low Moderate * High
5.99205 5.99245
New Patient Level 99201 99202 99203 99204 99205
Consultation 99241 99242 99243 99244 99245

Example: If History is EPF, Exam is Detailed, MDM is Moderate complexity the E&M level will be 99202
for New Patient office Visit, 99242 for Out-patient consultation 3/3 elements are satisfied.
.
 Level Of E&M for Established Patient(2/3)

There are five levels of E&M service for Established Patient.

1.99211 Table For Established Patient

2.99212 History PF EPF * Detailed Comprehensive
3.99213 Exam PF EPF Detailed * Comprehensive
4.99214
5.99215 MDM SF Low Moderate * High
Level 99211 99212 99213 99214 99215

Example: If History is EPF, Exam is Detailed, MDM is Moderate complexity the E&M level
will be 99214 for Established Patient office Visit as 2/3 elements are satisfied.