E and M Services
When a patient is seen as a consultation or new referral, all three of the key components, History, Examination, and Medical Decision Making, must be reported and meet or exceed the stated requirements to qualify for a particular level of EM service. When an established patient (seen within the past three years) visit is reported, two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service. Although time is not taken into account as a factor for determining the level of E/M care during most patient visits, the CPT codebook includes the inclusion of time as an explicit factor to assist physicians in selecting the most
appropriate level of service. The CPT codebook and the Documentation Guidelines for Evaluation and Management Services do define specific circumstances which permits time to be the sole determining factor in E/M selection. When counseling and / or coordination of care comprises more than 50% of the time spent during an encounter, then time may be considered the key or controlling factor to qualify for a particular level of E/M service. This must be “face – to face” time with the patient or the family and may be unit / floor time when in the hospital. The latter includes the time in which the physician establishes and / or reviews the patient’s chart, examines the patient, writes notes, and communicates with other professionals and the patient’s family. This means that the amount of time spent in patient care is permitted to become the sole determining factor of the level of E/M service even if the physician did not perform or report any of the three key components. The physician must document the total length of time of the encounter plus a description of the counseling and / or activities involved in the coordination of care.
The record documentation must also state that more than 50% of the encounter was involved in counseling and / or coordination of care. When the physician defines that more than 50% of the visit time was dedicated to counseling and coordination of care, the E/M code can be determined by the time values that are listed in the CPT codebook for each type of E/M service and each level of care. The CPT codebook also points out that the specific times expressed in the visit code descriptors are averages, and represent a range of times that may be higher or lower depending on the actual clinical situation. In the management of headache patients, office visits are often spent in counseling and coordination of care. Physicians treating headache patients should consider using the amount of time and effort spent performing this service as a determining factor in defining any particular office or hospital visit.
GENERAL E/M GUIDELINES
• Descriptors for the levels of E/M services recognize seven components used in defining the levels of E/M services
– History*
– Examination*
– Medical decision making*
– Counseling
– Coordination of care
– Nature of presenting problem and
– Time
*Key components Visits that consist predominately of counseling and/or coordination of care are an exception to this rule. For these visits, time is the key or controlling factor to qualify for a particular level of E/M services.