Evaluation and Management Services

Evaluation and Management Services:

E/M services refer to visits and consultations furnished by physicians and the following
qualified professionals,
Nurse practitioners, 

Clinical nurse specialists, 

Certified nurse midwives and Physician assistants.  

SELECTING THE E&M: 

Billing Medicare for an E/M service requires the selection of a Current Procedural Terminology code that best represents,

1. Patient type

2. Setting of service

3. Level of E/M service performed.  

PATIENT TYPE:

For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.  

A new patient is defined as an individual who has not received any professional services from the physician/non-physician practitioner or another physician of the same specialty who belongs to the same group practice within the previous three years. 

An established patient is an individual who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the previous three years.

SETTING OF SERVICE:

E/M services are categorized into different settings depending on where the service is furnished. Examples of settings include,

1. Office or other outpatient setting
2. Hospital inpatient
3. Evaluation and Management Services Guide
4. Emergency department
5. Nursing facility

LEVEL OF EVALUATION AND MANAGEMENT SERVICE PERFORMED

The code sets used to bill for E/M services are organized into various categories and levels. In general, the more complex the visit, the higher the level of code the physician may bill within the appropriate category. 

In order to bill any code, the services furnished must meet the definition of the code. It is the physician’s responsibility to ensure that the codes selected reflect the services furnished. 

There are three key components when selecting the appropriate level of E/M service provided: 

1. History, 

2. Examination, and 

3. Medical decision making. 

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

A. History:

Consists of 3 Major components are mentioned below,

1. HPI

2. ROS

3. PFSH

Chief Complaint :
A Chief Complaint is describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The Chief Complaint is usually given by the patient. For example, patient complains of chest pain.

HPI (History of Present Illness)

HPI is the description of the development of the patient’s present illness.

HPI elements are listed below,

1. Location
2. Quality 

3. Severity 

4. Duration 

5. Timing 

6. Context 

7. Modifying factors 

8. Associated signs and symptoms.

There are two types of HPI:  

1. Brief and 

2. Extended.

A brief HPI includes documentation of one to three HPI elements. 

A extended HPI includes documentation of four or more HPI elements.

ROS: Review of Systems

ROS is obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following systems are recognized for ROS purposes:

1. Constitutional Symptoms (for example, fever, weight loss)
2. Eyes,

3. Ears, Nose, Mouth, Throat,

4. Cardiovascular, 

5. Respiratory, 

6. Gastrointestinal, 

7. Genitourinary, 

8. Musculoskeletal,

9. Integumentary (skin and/or breast); 

10. Neurological,

11. Psychiatric,

12. Endocrine,

13. Hematologic/Lymphatic; and 

14. Allergic/Immunologic.

There are three types of ROS: 

1. Problem pertinent, 

2. Extended, and 

3. Complete

A problem pertinent ROS- Minimum one system is reviewed
Extended ROS - Two to nine systems were reviewed
Complete ROS - Minimum of ten systems were reviewed

PFSH - Past, Family, and/or Social History 

PFSH consists of a review of three areas:

1. Past history including experiences with illnesses, operations, injuries, and treatments.
2. Family history including diseases, and hereditary conditions that may place the patient at risk.
3. Social history including an age appropriate review of past and current activities.

 The two types of PFSH are:

1. Pertinent and
2. Complete

The pertinent PFSH must document at least one item from any of the three history areas.
Complete PFSH is a review of two history areas is sufficient.

Note:
The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.