Evaluation and Management

Coding for an office visit, home visit, hospital inpatient services and more are all found in the evaluation and management section.

It is of the utmost importance that Medical Coders be aware of the guidelines that are associated with E/M and how to level out an E/M code.

It can be overwhelming to new and experienced coders alike I am going to try to help make E/M an easier concept for you today!

Grab your CPT book and follow along… a video will be posted below too

Starting with Office and outpatient services

There are 5 levels of codes for new and established patients

according to the CMS website a new patient is

New Patient:
An individual who did not receive any professional services from the
physician/non-physician practitioner (NPP) or another physician of the same specialty
who belongs to the same group practice within the previous 3 years

Established Patient:
An individual who received professional services from the
physician/NPP or another physician of the same specialty who belongs to the same

group practice within the previous 3 years

(cms.gov, evaluation and management guide, 2016).
When you begin coding and look at the chart the first question you must ask yourself is what type of patient are we dealing with? New or Established
For all new patients you will need to meet all 3 key components through documentation and for all established patients you will only need to meet 2 of the 3 key components through documentation
Remember documentation is your friend and like best friends that tell each other everything you need your documentation to tell you everything about the visit.
Leveling the code
you will see when you turn in your CPT book to the beginning of E/M section(see video below) that you have 5 levels of codes to choose from starting from a problem focused exam all the way to a comprehensive exam (the levels add in intensity)
There are 3 key components
  1. exam
  2. history
  3. medical decision making

you will need to know which set of guidelines your provider is using(I will link to the official guidelines below)

1995 or 1997 guidelines– according to the CMS a provider can choose which guidelines to follow, use the set of guidelines that are most beneficial to the provider

It will definitely help to have an E/M audit tool to help you get to the right level but this is a whole new post coming soon:) in this particular post I just want to give you a brief overview of the E/M section!



This key component has a 8 sub-components

HPI(history of present illness)

  1. location
    • where the patients chief complaint is located
      • example: patient presents with nasal congestion and headaches, post nasal drip
        • the location is in the head(respiratory system/ sinuses)
  2. duration
    • how long has the symptoms been happening
      • example: the patient began suffering from congestion 5 days ago
  3. timing
    • when does the symptoms happen
      • example: the patient experiences a heavy feeling in the head at night and symptoms seem worse first thing in the morning
  4. quality
    • explains the signs and symptoms(dull, heavy, sharp, stabbing….)
      • example: The patient describes the pain as a dull pain almost like a toothache that wont go away, the throat is beginning to feel a burning sensation more than likely from the drainage patient is experiencing.
  5. severity
    • on a scale of 1-10 how bad are the symptoms(you will typically see this for a pain scale)
      • example: on a scale of 1-10 the patient says that her symptoms are a 9
  6. associated signs and symptoms
    • any additional signs and symptoms that are not necessarily part of the main chief complaint
      • example: patient expresses that the past 2 days she has felt nauseous patient denies vomiting or diarrhea
  7. Context
    • what happens when the symptoms are apparent
      • example:
  8. modifying factors
    • this is anything that makes the signs and symptoms worse or better
      • Patient expresses that the symptoms are relieved only during a hot steamy shower, working seems to make it worse as the patient works in a chemical plant(very noisy and bright lights)

ROS (review of systems)

Review of systems is basically an inventory of body systems this is where the provider asks a series of questions to the patient regarding his/her signs and symptoms and chief complaint. the following is a list of the systems included in the ROS

  • Constitutional
  • Eyes
  • ™Ears, nose, mouth, throat
  • ™Cardiovascular
  • ™Respiratory
  • ™Gastrointestinal
  • ™Genitourinary
  • ™Musculoskeletal
  • ™Integumentary (skin and/or breast)
  • ™Neurological
  • ™Psychiatric
  • ™Endocrine
  • ™Hematologic/lymphatic
  • ™Allergic/immunologic

PFSH(past family social history)

this section will include any relative family history, social history includes marital status, and alcohol, smoking, recreational drug usage…


The work that goes into the patient visit, any labs ordered that needs to be reviewed, any medication changes, any risk to the patient,if the problems are worsening or improving


Evaluation and management is a complex section of procedural coding and this is the focus of many medical audits! Medical Coders want to be well versed in E/M coding to be successful.

 Do you feel you need a review session on E/M? You are in luck  Americode Professional Coding has just that– a Complex review session on E/M– each component of E/M is broken down into a lesson– Interested yet? find the entire course list above
Happy Coding

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