Note for E/M Audio/Visual Training Slide 26
Note for E/M Audio/Visual Training Slide 26
The three key components used in choosing an Evaluation and Management (E/M) code are the history, exam, and medical decision-making. We state in our presentation that for a subsequent care code, a provider would need to perform all three components, but use only two in determining the level of service to submit to Medicare.
We received questions on this statement. There are multiple pieces of information published in both the Current Procedural Terminology (CPT) book and the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) that indicate all three have to be performed, and there are other references in these same publications that would indicate only two have to be performed.
CMS provided clarification on this question and referred us to the General Principles of Medical Documentation in the CPT and to the Medical Record Documentation on page 5 of the CMS publication "Evaluation and Management Services Guide."
The CPT book states in part: "The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For E/M services, the nature and amount of physician work and documentation varies by type of service, place of services, and the patient's status. The general principles below may be modified to account for these variable circumstances in providing E/M services."
The CPT goes on to say, "The documentation of each patient encounter should include:
- The reason for the encounter as well as relevant history, physician examination findings and prior diagnostic tests results;
- An assessment, clinical impression or diagnosis;
- The plan for care; and
- Date and legible identity of the observer."
Page Last Updated: Thursday, 18-Mar-2010 05:56:45 CDT
