Chapter 23
Evaluation & Management

23.1 Prolonged Physician Services

Payment will be allowed for procedure codes 99354 (prolonged physician service in the office or other outpatient setting; first hour), 99355 (prolonged physician service in the office or other outpatient setting; each additional 30 minutes), 99356 (prolonged physician service in the inpatient setting; first hour), and 99357 (prolonged physician service in the inpatient setting; each additional 30 minutes) when the following criteria are met:
The physician has furnished and billed one of the procedure codes listed in column 1 as well as the corresponding code(s) in column 2 for the patient on the same day.
Office or other Outpatient Setting:
99354   99201 - 99205
99212 - 99215
99241 - 99245
99355 - 99354 plus one of the codes required for 99354

  Inpatient Setting:
99356   99221 - 99223
99231 - 99233
99251 - 99255
99261 - 99263
99301 - 99303
99311 - 99313
99357 - 99356 plus one of the codes required for 99356

The time counted toward payment for prolonged evaluation & management services included only direct face-to-face contact between the physician and the patient (whether or not the service was continuous).
The medical record documents the content of the evaluation and management service code, the duration and content of prolonged services that the physician personally furnished after the typical time of the evaluation & management service has been exceeded by at least 30 minutes.
Documentation need not be submitted to the carrier for processing purposes.
Following are examples of correct reporting of prolonged physician services with direct patient contact in
an office setting. The number in parentheses following the code represents the number of units reported for the code:

 

Duration of
Prolonged Services

Code to Report

Less than 30 minutes Not reported separately
30 - 74 minutes 99354 (1)
75 - 104 minutes 99354 (1) and 99355 (1)
105 - 134 minutes 99354 (1) and 99355 (2)
135 - 164 minutes 99354 (1) and 99355 (3)
165 - 194 minutes 99354 (1) and 99355 (4)

23.2 Physician Care Plan Oversight Services

In general, Medicare continues to consider care plan oversight services to be included in the payment for other services. However, Medicare allows separate payment for care plan oversight services under the following conditions:

a. Payment to Medical Directors of Home Health Agencies for Care Plan Oversight

Medical Directors of home health agencies can bill for care plan oversight if they meet the following criteria:

Medical Directors may bill for this service if:

They do not have significant ownership in or a significant financial relationship with the home health agency.

1. having a direct or indirect ownership interest of 5 percent or more in the capital, stock, or the profits of the home health agency.

2. having an ownership interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation that is secured by the agency, if that interest equals 5 percent or more of the agency's assets.

1. receiving any compensation as an officer or director (i.e., board of directors) of the home health agency.

2. having direct or indirect business transactions with the home health agency, in any year, amount to more than $25,000 or 5 percent of the agency's total operating expenses, whichever is less. Business transactions mean contracts, agreements, purchase orders, or leases to obtain services supplies, equipment, and space.

Note: If you would like additional information, please refer to Section 424.22 of the Code of Federal Regulations.

No separate payment will be allowed for care plan oversight services to physicians who have a significant ownership interest in, or a significant financial or contractual relationship with, a home health agency (HHA). For hospice patients, payment will only be made to the attending physician. Payment will not be made for care plan oversight services furnished by the hospice medical director, even if he/she is the patient's attending physician, or to physician who are employees of or providing services under arrangement with the hospice,

b. Volunteer Hospice Medical Directors

Volunteer hospice medical directors cannot bill for physician care plan oversight services. Section 418.3 of the Code of Federal Regulations (CFR) states that a volunteer within a hospice is considered an employee of the hospice. Payments to the hospice already include payment for services of the hospice physicians in establishing and overseeing the plans of care. Separate Part B payments are limited to physicians that are not affiliated with the hospice (see CFR 418-304). Thus, the volunteer medical director is considered an employee of the hospice and can not bill separately for care plan oversight under the physician fee schedule.

c. Services that are not Medically Necessary

Although a Regional Home Health Intermediary has approved payment for either home health or hospice care, this does not automatically mean that care plan oversight can be billed. The care plan oversight services must be of a type and duration for which separate payment is warranted. At least 30 minutes of the physician's time must be spent in medically necessary activities of the type described by CPT code 99375. Participation of a beneficiary in covered hospice or home health care does not alone qualify the beneficiary's physician for separate payment of care plan oversight services.

d. Questions and Answers

Some physicians have raised the following questions concerning care plan oversight services.

Q1. What physician activities are considered care plan oversight services for which separate payment is allowed?

A1. Care plan oversight includes the following physician activities: development or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication with other health care professionals involved in the patient's care, integration of new information into the medical treatment plan, and/or adjustment of medical therapy. Care plan oversight does not include the routine pre-and post-service work associated with visits and procedures. Also, telephone calls with patients and/or their families are not included.

Q2. What documentation is required?

A2. Physicians claiming payment for care plan oversight services must document in their records the care plan oversight services they furnish, including the dates and exact duration of time spent on the services for which payment is claimed. Care plan oversight is recognized by Medicare as a physician service and must be provided and documented only by the responsible physician.

Q3. How will beneficiaries know that they may be responsible for additional coinsurance payments for care plan oversight services?

A3. Since care plan oversight services do not typically involve a face-to-face encounter between the patient and the physician, the patient may not be aware that the services were provided. Physicians can help by informing their patients that Medicare will pay for these services when the specified conditions are met. Beneficiaries will also be notified regarding allowed care plan oversight services in their Explanation of Your Medicare Part B Benefits messages.

23.3 Inpatient Dialysis and Evaluation/Management

Payment for Evaluation and Management (E&M) procedure codes 99231-99233 and 99261-99263 will be bundled into payment for inpatient dialysis procedures 90935-90947 for services rendered on or after January 1, 1995. No payment will be made for the E&M visits if billed the same day as inpatient dialysis.

23.4 Initial Evaluation and Management Procedure Codes

Initial hospital care codes (99221-99223) are used to report the first hospital inpatient encounter with the patient by the admitting physician. Only one initial hospital evaluation and management (E&M) procedure code (i.e., 99221-99223) may be reported per hospital stay. Subsequent evaluation and management services should be reported by using the appropriate subsequent hospital care procedure code (i.e., 99231-99233).

For initial inpatient encounters by physicians other than the admitting physician, the subsequent hospital care codes (99231-99233) or the initial inpatient consultation codes (99251-99255) should be reported as appropriate.

When more than one initial hospital evaluation and management procedure code is reported during a single hospital stay only one initial hospital E&M will be allowed. The remainder of the initial hospital E&M services will be denied as incorrect reporting. These subsequent hospital care services may be resubmitted with the appropriate subsequent hospital care procedure codes (99231-99233).

a. Routine Physical Exam

A physician may bill Medicare beneficiaries for the non-covered portion of a physical exam performed in conjunction with a covered visit. When a physician furnishes a routine physical exam as well as a medically indicated or covered visit during the same encounter, the covered visit is viewed as being provided in lieu of a part of the routine physical. The physician may charge the beneficiary (as a charge for the non-covered portion of the routine physical) the difference between the physician's current established charge for the routine physical and his/her current established charge for the covered visit. It should be noted that the covered portion of the routine physical exam, which is billed with an established evaluation and management code, is subject to the limiting charge.

The physician is not required to give the beneficiary written advance notice of non-coverage because Medicare coverage of routine physical examinations is denied on the basis of the statutory exclusion.

The preventive services codes (99381-99397) should be used to report the non-covered portion of the visit. Providers are encouraged to file a claim for these services if the Medicare beneficiary wishes a Medicare determination of coverage either for supplemental insurance purposes or if the patient believes the service may be covered, despite advice to the contrary from the physician.

23.5 Critical Care (CPT Codes 99291 and 99292)

a. Definition of Critical Illness or Injury

The AMA’s CPT has redefined a critical illness or injury as follows:

“A critical illness or injury acutely impairs one or more vital organ systems such that the patient’s survival is jeopardized.”

Note: The term “unstable” is no longer used in the CPT definition to describe critically ill or injured patients.

b. Definition of Critical Care Services

CPT 2000 has redefined critical care services as follows:

“Critical care is the direct delivery by a physician(s) of medical care for a critically ill or injured patient. The care of such patients involves decision making of high complexity to assess, manipulate, and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple vital organ system failure or to prevent further deterioration. It may require extensive interpretation of multiple databases and the application of advanced technology to manage the patient. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient’s condition continues to require the level of physician attention described above.”

“Critical care services include but are not limited to, the treatment or prevention or further deterioration of central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, post operative complications, or overwhelming infection. Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility.”

The following procedures are to be bundled into the payment of critical care (99291 and 99292) when provided on the same day, by the same physician administrating the critical care:
Code Description

c. Guidelines for Use of Critical Care Codes

In order to reliably and consistently determine that delivery of critical care services rather than other evaluation and management services is medically necessary, both of the following medical review criteria must be met in addition to the CPT definitions:

There is a high probability of sudden, clinically significant, or life threatening deterioration in the patient’s condition which requires the highest level of physician preparedness to intervene urgently.

Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.

Providing medical care to a critically ill patient should not be automatically determined to be a critical care service for the sole reason that the patient is critically ill. The physician service must be medically necessary and meet the definition of critical care services as described previously in order to be considered covered.

EXAMPLE: A dermatologist treating a rash on an ICU patient who is maintained on a ventilator and nitroglycerine drip which are being managed by an intensivist should not bill for critical care.

d. “Full Attention” Requirement For Critical Care Service

Constant attendance is no longer a prerequisite for use of critical care codes. Critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time.

e. Reporting of Physician Time Toward Critical Care Time

CPT 2000 states the following: “Time spent with the individual patient should be recorded in the patient’s record. The time that can be reported as critical care is the time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit. For example, time spent on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff or documenting critical care services in the medical record would be reported as critical care, even though it does not occur at the bedside. Also, when the patient is unable or clinically incompetent to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the medical decision making.”

“Time spent in activities that occur outside of the unit or off the floor (e.g., telephone calls, whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care since the physician is not immediately available to the patient. Time spent in activities that do not directly contribute to the treatment of the patient may not be reported as critical care, even if they are performed in the critical care unit (e.g., participation in administrative meetings or telephone calls to discuss other patients).”

f. Medical Review Guidelines Regarding “Full Attention” and Physician Time in Critical Care Services.

a) the patient is unable or incompetent to participate in giving a history and/or making treatment decisions,
b) the discussion is absolutely necessary for treatment decisions under consideration that day, and
c) all of the following are documented in the physician’s progress note for that day:

(i) the patient was unable or incompetent to participate in giving history and/or making treatment decisions, as appropriate,
(ii) the necessity of the discussion (e.g., no other source was available to obtain a history” or “because the patient was deteriorating so rapidly needed to discuss treatment options with family immediately”),
(iii) the treatment decisions for which the discussion was needed, and
(iv) the substance of the discussion as related to the treatment decision.

The physician’s progress note must link the family discussion to a specific treatment issue and explain why the discussion was necessary on that day.

All other family discussions, no matter how lengthy, may not be counted towards critical care time. Examples of family discussions which do not meet the appropriate criteria include:

Telephone calls to family members and surrogate decision makers must meet the same conditions as face-to-face meetings.

g. Non Critically Ill or Injured Patients in a Critical Care Unit

Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes
This means that the care of a patient who receives medical care in a critical care, intensive care, or other specialized care unit should not be reported with critical care codes unless the services:

Examples of patients who may not satisfy Medicare criteria for critical care payment include:

Care of patients which does not meet all these criteria should be reported using the appropriate evaluation and management codes (e.g., subsequent hospital visit codes 99231 - 99233, or inpatient consultation codes 99251 - 99255) depending on the level of service provided.

h. Hours And Days Of Critical Care That May Be Billed

Critical care time may be continuous or interrupted.

i. Global Surgery

Use of modifier “-25” to permit payment of critical care on the day of a procedure with a global fee period.

Services with a 0, 10, or 90 day global period such as endotracheal intubation (CPT code 31500) cardiopulmonary resuscitation (CPT code 92950) the insertion, and placement of a flow directed catheter e.g., Swan-Ganz, (CPT code 93503) are not bundled into the critical care codes. Separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and it was reported with modifier “-25”. The time spent performing these unbundled services, e.g., endotracheal intubation, is excluded from the determination of the time spent providing critical care.

j. Teaching Physician Rules for Critical Care Billing

For procedure codes determined on the basis of time, such as critical care, the teaching physician must be present for the period of time for which the claim is made. For example, payment will be made for 35 minutes of critical care services only if the teaching physician is present for the full 35 minutes.

Time spent teaching may not be counted towards critical care time. Time spent by the resident in the absence of the teaching physician cannot be billed by the teaching physician as critical care. Only time spent by the resident and teaching physician together with the beneficiary or the teaching physician alone with the beneficiary can be counted toward critical care time.

k. Ventilator Management

The Medicare Physician Fee Schedule final rule, published on December 10, 1993, established national policy of paying for either an E/M service or ventilator management but not both. The final rule states, “We will continue to recognize the ventilator management codes (CPT codes 94656, 94657, 94660, and 94662) as physician services payable under the physician fee schedule. Physicians will no longer be paid for ventilation management in addition to an evaluation and management service, even if the evaluation and management service is billed with CPT modifier “-25”.”

23.6 "Incident To" Services

Medicare defines "incident to" services as those services and supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. In other words, these services do not represent the major portion of the overall service provided to a beneficiary by the physician. To be covered incident to the services of a physician, services and supplies must be:

a. Commonly Furnished in Physicians' Offices

Services and supplies commonly furnished in physicians' offices are covered under the incident to provision. Where supplies are clearly of a type a physician is not expected to have on hand in his/her office or where services are of a type not considered medically appropriate to provide in the office setting, they would not be covered under the incident to provision.

Supplies usually furnished by the physician in the course of performing his/her services, e.g., gauze, ointments, bandages, and oxygen are also covered. Charges for such services and supplies must be included in the physicians' bills. To be covered, supplies, including drugs and biologicals, must represent an expense to the physician. For example, where a patient purchases a drug and the physician administers it, the cost of the drug is not covered.

b. Direct Personal Supervision
Coverage of services and supplies incident to the professional services of a physician in private practice is limited to situations in which there is
direct physician supervision. This applies to services of auxiliary personnel employed by the physician and working under his or her supervision, such as nurses, nonphysician anesthetists, psychologists, technicians, therapists, including physical therapists, and other aides. Thus, where a physician employs auxiliary personnel to assist him/her in rendering services to patients and includes the charges for their services in his/her own bills, the services of such personnel are considered incident to the physician's service if:

b.1 Office Setting

Direct personal supervision in the office setting does not mean that the physician must be physically present in the same room with the auxiliary personnel. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the auxiliary personnel is performing services. Availability of the physician by telephone does not constitute direct personal supervision.

b.2 Outside the Office Setting

Outside the office setting (e.g., in a patient's home or in a nursing facility), direct personal supervision requires the physician to have face-to-face contact with the patient and to be in the room while the auxiliary personnel is rendering the service. The physician must remain with the patient and auxiliary personnel for the duration of the treatment. The availability of the physician by telephone and the presence of the physician somewhere in the institution does not constitute direct personal supervision. (See special instructions further in this section regarding homebound patients in medically underserved areas).

When a physician has an office within a nursing home or other institution, services performed by employees of the physician outside the "office" area must be directly supervised by the physician. The services of a physician's nonphysician employee can be covered in this circumstance only if the physician accompanies the nonphysician to treat the patient and directly supervises the nonphysician services for the duration of the treatment. The physician's presence in the "office" or other area of the institution does not suffice to meet this requirement. As with all services, payment for services rendered in an office established within an institution, must be reasonable and necessary for the individual patient's condition.

b.3 Hospital Services

Section 1862(a)(14) of the Social Security Act provides that every service to hospital inpatients and outpatients, except for the professional services of physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists, as well as qualified psychologist services must be provided by the hospital directly, or by others under arrangements made by the hospital, and only the hospital may bill its Medicare intermediary for the services. If the services are not provided and billed for in this way, they are not covered by Medicare. This is sometimes referred to as the hospital "bundling" provision. This provision is applicable to all hospital patients where a Medicare payment can be made to the hospital, including patients in psychiatric hospitals.

This means that services and supplies that would normally be covered "incident to" in an office setting, such as the services of nurses and other clinical assistants that physicians hire and supervise, are not billable by the physician in hospital settings. Physicians must personally perform the service in order for it to be payable in a hospital setting.

c. Employment

To be considered an employee for purposes of this section, the nonphysician performing an incident to service may be a part-time, full-time, or leased employee of the supervising physician, physician group practice, or of the legal entity that employs the physician (hereafter referred to collectively as the physician or other entity) who provides personal supervision (as described below). A leased employee is a nonphysician working under a written employee leasing agreement which provides that:

In order to satisfy the employment requirement, the nonphysician (either leased or directly employed) must be considered an employee of the supervising physician or other entity under the common law test of an employer/employee relationship specified in §210(j)(2) of the Act, 20 CFR 404.1007, and §RS 2101.102 of the Retirement and Survivors Insurance part of the Social Security Program Operations Manual System.

Services provided by auxiliary personnel not in the employ of the physician, physician group practice, or other legal entity, even if provided on the physician's order or included in the physician's bill are not covered as incident to a physician's service since the law requires that the services be of kinds commonly furnished in physicians' offices and commonly either rendered without charge or included in physicians' bills. As with the physicians' personal professional service, the patient's liability for the incidental services is to the physician, physician group practice, or other legal entity. Therefore, the incidental service must represent an expense incurred by the physician or other entity responsible for providing the service.

d. Nonphysician Practitioner Services

Certain nonphysician practitioners, licensed by the state under various programs to assist or act in the place of the physician may also have their services covered incident to the services of a physician. These nonphysician practitioners include the following: certified nurse midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.

Services performed by these nonphysician practitioners incident to a physician's professional services can include not only services ordinarily rendered by a physician's office staff person (e.g., medical services such as taking blood pressures, temperatures, giving injections, and changing dressings) but also services ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient's condition.

A nonphysician practitioner, such as a physician assistant or a nurse practitioner, may be licensed under state law to perform a specific medical procedure. This practitioner may be able to perform the procedure without direct physician supervision and have the service separately covered and paid for by Medicare as a physician assistant's or nurse practitioner's service. However, in order to have the same service covered as "incident to" the services of a physician, it must be performed under the direct personal, supervision of the physician as an integral part of the physician's personal in-office service. There must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent service by the physician of a frequency that reflects the physicians' continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary.

e. Physician Directed Clinics

Services and supplies incident to a physician's service in a physician directed clinic or group association are generally the same as those described above.

A physician directed clinic is one where (a) a physician (or a number of physicians) is present to perform medical (rather than administrative) services at all times the clinic is open; (b) each patient is under the care of a clinic physician; and (c) the nonphysician services are under medical supervision.

In highly organized clinics, particularly those which are departmentalized, direct personal physician supervision may be the responsibility of several physicians as opposed to an individual attending physician. In this situation, medical management of all services provided in the clinic is assured. The physician ordering a particular service need not be the physician who is supervising the service. Therefore, services performed by therapists and other aides are covered even though they are performed in another department of the clinic.

Supplies provided by the clinic during the course of treatment are also covered. When the auxiliary personnel perform services outside the clinic premises, the services are covered only if performed under the direct personal supervision of a clinic physician. If the clinic refers a patient for auxiliary services performed by personnel who are not employed by the clinic, such services are not considered "incident to" a physician's service.

f. Other Nonphysician Providers Who May Bill for Services Incident To

Besides physicians, the Medicare law also provides coverage for services rendered incident to the services of other practitioners. These practitioners are as follows:

All criteria applicable to incident to services of a physician as described in this chapter are also applicable to services billed incident to the services of these nonphysician practitioners.

g. Billing Requirements for Incident to Services

Effective January 1, 1997, services provided `incident to' the personal professional services of a physician or nonphysician must be billed using the YR modifier in addition to any other applicable modifiers. Failure to use the modifier may subject the payments of these incorrectly billed claims to recoupment.

YR - services performed by another provider but billed as services performed `incident to' the personal professional services of the billing physician/nonphysician.

Services rendered incident to the services of a physician or nonphysician provider are reported and paid as though the physician/nonphysician provider personally performed the service. Although there are instances when the provider and the provider's employee collaborate on a service, the YR modifier should be reported with service codes when the employee performed the service predominantly without the provider's collaboration. Do not use this modifier when reporting laboratory tests, supplies, drugs, or biologicals. The YR modifier should not be used with codes which are typically not physician services, including:

h. General Supervision for Homebound Patients in Medically Underserved Areas

In some medically underserved areas, there are only a few physicians available to provide services over broad geographic areas or to a large patient population. The lack of medical personnel (and, in many instances, a home health agency servicing the area) significantly reduces the availability of certain medical services to homebound patients. Some physician and physician-directed clinics, therefore, call upon nurses and other paramedical personnel to provide these services under general (rather than direct) supervision.

Medicare provides coverage for individual or intermittent services listed below when they are performed by personnel meeting any pertinent state requirements (e.g., a nurse, a technician, or physician extender) and where the criteria listed below are met:

This coverage should not be considered as an alternative to home health benefits where there is a participating home health agency (HHA) in the area which could provide the needed services on a timely basis. Intermittent services (at least one every 60 days) for injection and venipuncture to homebound patients are usually not covered if the services are available from a HHA. In some instances, services under the supervision of a physician/clinic to homebound patients may be covered even though the services of an HHA are available to the area. Examples of such situations are:

1. Where the patient has exhausted home health benefits.

2. Where the HHA could not respond on a timely basis, or

3. Where the physician could not have foreseen that intermittent services would be needed, e.g., and more services are necessary.

The doctor's medical records for patients receiving these services must be appropriately documented and available for the carrier's review when requested.

Covered Services: Where the requirements mentioned above are met, the following services are eligible for homebound patients rendered under general supervision:

(a) the care of colostomy and ileostomy
(b) the care of permanent tracheostomy
(c) testing urine and care of the feet (diabetic patients only)
(d) blood pressure monitoring

Teaching and training services (also referred to as educational services) can be covered only where they provide knowledge essential for the chronically ill patient's participation in his own treatment and only where they can be reasonably related to such treatment or diagnosis. Educational services that provide more elaborate instruction than is necessary to achieve the required level of patient education are not covered. After essential information has been provided, the patient should be relied upon to obtain additional information for himself or herself.

Note: Please reference Medicare Medical Policy Bulletins (MMPB) Z-27 and Z-33 for additional information on Supervision Guidelines and Employment Relationship Criteria.

23.7 Documentation Guidelines for Evaluation & Management Services

These guidelines have been developed jointly by the American Medical Association (AMA) and the Health Care Financing Administration (HCFA). Our mutual goal is to provide physicians and claims reviewers with advice about preparing or reviewing documentation for Evaluation and Management (E/M) services. In developing and testing the validity of these guidelines, special emphasis was placed on assuring that they:

This edition contains a substantial amount of new material and a number of significant revisions in material that appeared in the first edition. Because of the extensive changes, the section on examination should be read in its entirety. In this edition:

The AMA and HCFA wish to thank the CPT Editorial Panel, the CPT Advisory Committees, the Practicing Physicians Advisory Council, and the Medicare Contractor Medical Directors for their thoughtful advice, comments and direction concerning the many complex issues that were addressed in the development of these guidelines. The AMA and HCFA are committed to continually improving these guidelines and welcome comments based on their usage.

a. What is documentation and Why is it Important?

Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:

An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary.

b. What Do Payers Want and Why?

Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate:

c. General Principles of Medical Record Documentation

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 service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include:

a. reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;

b. assessment, clinical impression or diagnosis;

c. plan for care; and

d. date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

d. Documentation of E/M Services

The following information provides definitions and documentation guidelines for the three key components of E/M services and for visits which consist predominately of counseling or coordination of care. The three key components-history, examination, and medical decision making-appear in the descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services. While some of the text of CPT has been repeated in this subsection, refer to your CPT for complete descriptors for E/M services and instructions for selecting a level of service. Documentation guidelines are identified by the symbol  DG.

The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. These components are:

The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service.

Because the level of E/M service is dependent on two or three key components, performance and documentation of one component (eg, examination) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service.

These Documentation Guidelines for E/M services reflect the needs of the typical adult population. For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area.

As an example, newborn records may include under history of the present illness (HPI) the details of mother's pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, the content of a pediatric examination will vary with the age and development of the child. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate.

e. Documentation of History

The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements:

The extent of history of present illness, review of systems and past, family and/or social history that is obtained and documented is dependent upon clinical judgement and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history all three elements in the table must be met. (A chief complaint is indicated at all levels.)

Documentation Elements (example)
 
 

History of Present Illness

(HPI)

Review of Systems 

(ROS)

Past, Family,and/or

Social History (PFSH)

Type of History

Brief N/A N/A Problem Focused
Brief Problem Pertinent N/A Expanded Problem Focused
Extended Extended Pertinent Detailed
Extended Complete Complete Comprehensive
 

Definitions and specific documentation guidelines for each of the elements of history are listed below.

e.1 Chief Complaint (CC)

The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words.

e.2 History of Present Illness (HPI)

The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

A brief HPI consists of one to three elements of the HPI.

An extended HPI consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions.

e.3 Review of Systems (ROS)

A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

For purposes of ROS, the following systems are recognized:

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

e.4 Past, Family and/or Social History (PFSH)

The PFSH consists of a review of three areas:

For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Those categories are subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI.

f. Documentation of Examination

The levels of E/M services are based on four types of examination:
 

These types of examinations have been defined for general multi-system and the following single organ systems:

  • Cardiovascular
  • Ears, Nose, Mouth and Throat
  • Eyes
  • Genitourinary (Female)
  • Genitourinary (Male)
  • Hematologic/Lymphatic/Immunologic
  • Musculoskeletal
  • Neurological
  • Psychiatric
  • Respiratory
  • Skin

A general multi-system examination or a single organ system examination may be performed by any physician regardless of specialty. The type (general multi-system or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgement, the patient's history, and the nature of the presenting problem(s).

The content and documentation requirements for each type and level of examination are summarized below and described in detail in the tables. In the tables, organ systems and body areas recognized by CPT for purposes of describing examinations are shown in the left column. The content, or individual elements, of the examination pertaining to that body area or organ system are identified by bullets () in the right column.

Parenthetical examples, "(eg, ...)", have been used for clarification and to provide guidance regarding documentation. Documentation for each element must satisfy any numeric requirements (such as "Measurement of any three of the following seven...") included in the description of the element. Elements with multiple components but with no specific numeric requirement (such as "Examination of liver and spleen") require documentation of at least one component. It is possible for a given examination to be expanded beyond what is defined here. When that occurs, findings related to the additional systems and/or areas should be documented.
 

f.1 General Multi-System Examinations

General multi-system examinations are described in detail. To qualify for a given level of multi-system examination, the following content and documentation requirements should be met:
 

f.2 Single Organ System Examinations
The single organ system examinations recognized by CPT are described below . Variations among these examinations in the organ systems and body areas identified in the left columns and in the elements of the examinations described in the right columns reflect differing emphases among specialties. To qualify for a given level of single organ system examination, the following content and documentation requirements should be met:
 

Comprehensive Examination - should include performance of all elements identified by a bullet,  whether in a shaded or unshaded box. Documentation of every element in a box with a shaded border and at least one element in a box with an unshaded border is expected.

f.3 Content and Documentation Requirements

a. General Multi-System Examination

System/Body Area 

Elements of Examination

Constitutional

  • Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height,7) weight (May be measured and recorded by ancillary staff) 
  • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Eyes

  • Inspection of conjunctivae and lids 
  • Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry) 
  • Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)

Ears, Nose, 

Mouth and Throat
  • External inspection of ears and nose (eg, overall appearance, scars, lesions, masses) 
  • Otoscopic examination of external auditory canals and tympanic membranes 
  • Assessment of hearing (eg, whispered voice, finger rub, tuning fork) 
  • Inspection of nasal mucosa, septum and turbinates
  • Inspection of lips, teeth and gums 
  • Examination of oropharynx: oral mucosa, salivary glands, hard 
    and soft palates, tongue, tonsils and posterior pharynx

Neck

  • Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) 
  • Examination of thyroid (eg, enlargement, tenderness, mass)

Respiratory

  • Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) 
  • Percussion of chest (eg, dullness, flatness, hyperresonance)
  • Palpation of chest (eg, tactile fremitus)
  • Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

  • Palpation of heart (eg, location, size, thrills)
    Auscultation of heart with notation of abnormal sounds and 
    murmurs 

    Examination of: 

  • carotid arteries (eg, pulse amplitude, bruits) 
  • abdominal aorta (eg, size, bruits) 
  • femoral arteries (eg, pulse amplitude, bruits) 
  • pedal pulses (eg, pulse amplitude) 
  • extremities for edema and/or varicosities 

Chest (Breasts)

  • Inspection of breasts (eg, symmetry, nipple discharge) 
  • Palpation of breasts and axillae (eg, masses or lumps, tenderness)

Gastrointestinal 

(Abdomen)
  • Examination of abdomen with notation of presence of masses or tenderness 
  • Examination of liver and spleen 
  • Examination for presence or absence of hernia 
  • Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
  • Obtain stool sample for occult blood test when indicated

Genitourinary

MALE:  

  • Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass)
  • Examination of the penis
  • Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness) 

FEMALE: 

Pelvic examination (with or without specimen collection for smears 
and cultures), including: 
 

  • Examination of external genitalia (eg, general appearance,hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) 
  • Examination of urethra (eg, masses, tenderness, scarring) 
  • Examination of bladder (eg, fullness, masses, tenderness) 
  • Cervix (eg, general appearance, lesions, discharge) 
  • Uterus (eg, size, contour, position, mobility, tenderness, 
    consistency, descent or support) 
  • Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity) 

Lymphatic

Palpation of lymph nodes in two or more areas: 

  • Neck 
  • Axillae 
  • Groin 
  • Other
Musculoskeletal
  • Examination of gait and station
  • Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes) 

    Examination of joints, bones and muscles of one or more of the following  six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity.The examination of a given area includes: 

  • Inspection and/or palpation with notation of presence of any misalignment, 
    asymmetry, crepitation, defects, tenderness, masses, effusions 
  • Assessment of range of motion with notation of any pain, crepitation or 
    contracture 
  • Assessment of stability with notation of any dislocation (luxation), 
    subluxation or laxity 
  • Assessment of muscle strength and tone (eg, flaccid, cogwheel, spastic) 
    with notation of any atrophy or abnormal movements 

Skin

  • Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers) 
  • Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)

Neurologic

  • Test cranial nerves with notation of any deficits
  • Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski)
  • Examination of sensation (eg, by touch, pin, vibration, proprioception)

Psychiatric

  • Description of patient's judgment and insight

Brief assessment of mental status including: 

  • orientation to time, place and person 
  • recent and remote memory 
  • mood and affect (eg, depression, anxiety, agitation) 
Contents and Documentation Requirements
Level of Exam  Perform and Document:
Problem Focused  One to five elements identified by a bullet.
Expanded Problem Focused At least six elements identified by a bullet.
Detailed  At least two elements identified by a bullet from each  
of six areas/systems OR at least twelve elements 
identified by a bullet
in two or more areas/systems.
Comprehensive Perform all elements identified by a bullet in at least  
nine organ systems or body areas and document at least  
two elements by a bullet from each of the nine areas/ systems.
b. Cardiovascular Examination

System/Body Area 

Elements of Examination

Constitutional

  • Measurement of any three of the following seven vital signs:1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
  • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Head and Face

 

Eyes

  • Inspection of conjunctivae and lids (eg, xanthelasma)

Ears, Nose, 

Mouth and Throat
  • Inspection of teeth, gums and palate
  • Inspection of oral mucosa with notation of presence of pallor or cyanosis

Neck

  • Examination of jugular veins (eg, distension; a, v or cannon a waves) 
  • Examination of thyroid (eg, enlargement, tenderness, mass)

Respiratory

  • Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) 
  • Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

  • Palpation of heart (eg, location, size and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4) 
  • Auscultation of heart including sounds, abnormal sounds and murmurs 
  • Measurement of blood pressure in two or more extremities when indicated (eg, aortic dissection, coarctation)

    Examination of: 

  • Carotid arteries (eg, waveform, pulse amplitude, bruits, 
    apical-carotid delay) 
  • Abdominal aorta (eg, size, bruits) 
  • Femoral arteries (eg, pulse amplitude, bruits) 
  • Pedal pulses (eg, pulse amplitude) 
  • Extremities for peripheral edema and/or varicosities 

Chest (Breasts)

 

Gastrointestinal 

(Abdomen)
  • Examination of abdomen with notation of presence of masses or tenderness 
  • Examination of liver and spleen
  • Obtain stool sample for occult blood from patients who are being considered for thrombolytic or anticoagulant therapy

Genitourinary

(Abdomen)
 

Lymphatic

 

Musculoskeletal

Examination of the back with notation of kyphosis or scoliosis 

Examination of gait with notation of ability to undergo exercise 
testing and/or participation in exercise programs 

Assessment of muscle strength and tone (eg, flaccid, cog wheel, 
spastic) with notation of any atrophy and abnormal movements

Extremities

Inspection and palpation of digits and nails (eg, clubbing, cyanosis, 
inflammation, petechiae, ischemia, infections, Osler's nodes)

Skin

Inspection and/or palpation of skin and subcutaneous tissue 
(eg, stasis dermatitis, ulcers, scars, xanthomas)

Neurological/

Psychiatric

Brief assessment of mental status including: 

  • Orientation to time, place and person, 
  • Mood and affect (eg, depression, anxiety, agitation) 
Content and Documentation Requirements
Level of Exam  Perform and Document:
Problem Focused  One to five elements identified by a bullet.
Expanded Problem Focused At least six elements identified by a bullet.
Detailed At least twelve elements identified by a bullet.
Comprehensive Perform all elements identified by a bullet; document 
every element in a box with a shaded border and at 
least one element in a box with an unshaded border.
c. Ear, Nose and Throat Examination

System/Body Area 

Elements of Examination

Constitutional

  • Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
  • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
  • Assessment of ability to communicate (eg, use of sign language or other communication aids) and quality of voice

Head and Face

  • Inspection of head and face (eg, overall appearance, scars, lesions and masses)
  • Palpation and/or percussion of face with notation of presence or absence of sinus tenderness
  • Examination of salivary glands 
  • Assessment of facial strength

Eyes

  • Test ocular motility including primary gaze alignment

Ears, Nose,

Mouth and Throat
  • Otoscopic examination of external auditory canals and tympanicmembranes including pneumo-otoscopy with notation of mobility of membranes 
  • Assessment of hearing with tuning forks and clinical speech reception thresholds (eg, whispered voice, finger rub)
  • External inspection of ears and nose (eg, overall appearance,scars, lesions and masses)
  • Inspection of nasal mucosa, septum and turbinates 
  • Inspection of lips, teeth and gums 
  • Examination of oropharynx: oral mucosa, hard and soft palates, tongue, tonsils and posterior pharynx (eg, asymmetry, lesions, hydration of mucosal surfaces) 
  • Inspection of pharyngeal walls and pyriform sinuses (eg, pooling of saliva, asymmetry, lesions) 
  • Examination by mirror of larynx including the condition of the epiglottis, false vocal cords, true vocal cords and mobility of larynx (Use of mirror not required in children) 
  • Examination by mirror of nasopharynx including appearance of the mucosa, adenoids, posterior choanae and eustachian tubes (Use of mirror not required in children)

Neck

  • Examination of neck (eg, masses, overall appearance, symmetry,tracheal position, crepitus)
  • Examination of thyroid (eg, enlargement, tenderness, mass)

Respiratory

  • Inspection of chest including symmetry, expansion and/or assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)
  • Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

  • Auscultation of heart with notation of abnormal sounds and murmurs
  • Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

 

Gastrointestina

(Abdomen)
 

Genitourinary

 

Lymphatic

  • Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal

 

Extremities

 

Skin

 

Neurological/

Psychiatric
  • Test cranial nerves with notation of any deficits 
    Brief assessment of mental status including: 
  • Orientation to time, place and person, 
  • Mood and affect (eg, depression, anxiety, agitation) 
Content and Documentation Requirements
Level of Exam  Perform and Document:
Problem Focused  One to five elements identified by a bullet.
Expanded Problem Focused At least six elements identified by a bullet.
Detailed At least twelve elements identified by a bullet.
Comprehensive Perform all elements identified by a bullet; document 
every element in a box with a shaded border and at least 
one element in a box with an unshaded border.
d. Eye Examination

System/Body Area 

Elements of Examination

Constitutional

 

Head and Face

 

Eyes

  • Test visual acuity (Does not include determination of refractive error) 
  • Gross visual field testing by confrontation 
  • Test ocular motility including primary gaze alignment 
  • Inspection of bulbar and palpebral conjunctivae
  • Examination of ocular adnexae including lids (eg, ptosis or lagophhalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes
  • Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size (eg, anisocoria) and morphology
  • Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film
  • Slit lamp examination of the anterior chambers including depth, cells, and flare
  • Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus
  • Measurement of intraocular pressures (except in children and patients with trauma or infectious disease) 

    Ophthalmoscopic examination through dilated pupils (unless contraindicated) of 

  • Optic discs including size, C/D ratio, appearance (eg, at rophy, cupping, tumor elevation) and nerve fiber layer 
  • Posterior segments including retina and vessels (eg, exudates and hemorrhages) 

Ears, Nose, Mouth

and Throat
 

Neck

 

Respiratory

 

Cardiovascular

 

Chest (Breasts)

 

Gastrointestinal (Abdomen)

 

Genitourinary

 

Lymphatic

 

Musculoskeletal

 

Extremities

 

Skin

 

Neurological/ 

Psychiatric

Brief assessment of mental status including 

  • Orientation to time, place and person 
  • Mood and affect (eg, depression, anxiety, agitation) 
Content and Documentation Requirements
Level of Exam  Perform and Document:
Problem Focused  One to five elements identified by a bullet.
Expanded Problem Focused At least six elements identified by a bullet.
Detailed At least nine elements identified by a bullet.
Comprehensive Perform all elements identified by a bullet; document 
every element in a box with a shaded border and at least 
one element in a box with an unshaded border.
e. Genitourinary Examination

System/Body Area 

Elements of Examination

Constitutional

  • Measurement of any three of the following seven vital signs:1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
  • General appearance of patient (eg, development, nutrition, bodyhabitus, deformities, attention to grooming)

Head and Face

 

Eyes

 

Ears, Nose,

Mouth and Throat
 

Neck

  • Examination of neck (eg, masses, overall appearance, symmetry,tracheal position, crepitus)
  • Examination of thyroid (eg, enlargement, tenderness, mass)

Respiratory

  • Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) 
  • Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

  • Auscultation of heart with notation of abnormal sounds and murmurs 
  • Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

[See genitourinary (female)]

Gastrointestinal

(Abdomen)
  • Examination of abdomen with notation of presence of masses or tenderness 
  • Examination for presence or absence of hernia
  • Examination of liver and spleen 
  • Obtain stool sample for occult blood test when indicated

Genitourinary 

MALE: 
 

  • Inspection of anus and perineum 
    Examination (with or without specimen collection for smears and cultures) of genitalia including: 
  • Scrotum (eg, lesions, cysts, rashes) 
  • Epididymides (eg, size, symmetry, masses) 
  • Testes (eg, size, symmetry, masses) 
  • Urethral meatus (eg, size, location, lesions, discharge) 
  • Penis (eg, lesions, presence or absence of foreskin, fore skin 
    retractability, plaque, masses, scarring, deformities) 

Digital rectal examination including: 

  • Prostate gland (eg, size, symmetry, nodularity, tenderness) 
  • Seminal vesicles (eg, symmetry, tenderness, masses, 
    enlargement) 
  • Sphincter tone, presence of hemorrhoids, rectal masses 

FEMALE: 

Includes at least seven of the following eleven elements identified 
by bullets: 

  • Inspection and palpation of breasts (eg, masses or lumps, tenderness, symmetry, nipple discharge)
  • Digital rectal examination including sphincter tone, presence of hemorrhoids,rectal masses

Pelvic examination (with or without specimen collection for smears and cultures) including: 

  • External genitalia (eg, general appearance, hair distribution, lesions)
  • Urethral meatus (eg, size, location, lesions, prolapse)
  • Urethra (eg, masses, tenderness, scarring)
  • Bladder (eg, fullness, masses, tenderness)
  • Vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
  • Cervix (eg, general appearance, lesions, discharge) 
  • Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)
  • Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
  • Anus and perineum 

Lymphatic

  • Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal

 

Extremities

 

Skin

  • Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)

Neurological/ 

Psychiatric

Brief assessment of mental status including: 

  • Orientation (eg, time, place and person) and 
  • Mood and affect (eg, depression, anxiety, agitation) 
Content and Documentation Requirements
Level of Exam  Perform and Document:
Problem Focused  One to five elements identified by a bullet.
Expanded Problem Focused At least six elements identified by a bullet.
Detailed At least twelve elements identified by a bullet.
Comprehensive Perform all elements identified by a bullet; document 
every element in a box with a shaded border and at least 
one element in a box with an unshaded border.
f. Hematologic/Lymphatic/Immunologic Examination

System/Body Area 

Elements of Examination

Constitutional

  • Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) 
  • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Head and Face

  • Palpation and/or percussion of face with notation of presence or absence of sinus tenderness

Eyes

  • Inspection of conjunctivae and lids

Ears, Nose, Mouth

& Throat
  • Otoscopic examination of external auditory canals and tympanic membranes 
  • Inspection of nasal mucosa, septum and turbinates
  • Inspection of teeth and gums
  • Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils, posterior pharynx)

Neck

  • Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) 
  • Examination of thyroid (eg, enlargement, tenderness, mass)

Respiratory

  • Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)
  • Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

  • Auscultation of heart with notation of abnormal sounds and murmurs
  • Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

 

Gastrointestinal

(Abdomen)
  • Examination of abdomen with notation of presence of masses or tenderness 
  • Examination of liver and spleen

Genitourinary

 

Lymphatic

  • Palpation of lymph nodes in neck, axillae, groin, and/or other location

Musculoskeletal

 

Extremities

Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)

Skin

  • Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers, ecchymoses, bruises)

Neurological/ 

Psychiatric

Brief assessment of mental status including: 

  • Orientation to time, place and person 
  • Mood and affect (eg, depression, anxiety, agitation) 
Content and Docmentation Requirement
Level of Exam  Perform and Document:
Problem Focused  One to five elements identified by a bullet.
Expanded Problem Focused At least six elements identified by a bullet.
Detailed  At least twelve elements identified by a bullet.
Comprehensive Perform all elements identified by a bullet; document 
every element in a box with a shaded border and at 
least one element in a box with an unshaded border.
g. Musculoskeletal Examination

System/Body Area 

Elements of Examination

Constitutional

  • Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
  • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Head and Face

 

Eyes

 

Ears, Nose, Mouth 

and Throat
 

Neck

 

Respiratory

 

Cardiovascular

  • Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

 

Gastrointestinal 

(Abdomen)
 

Genitourinary

 

Lymphatic

  • Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal

  • Examination of gait and station 

Examination of joint(s), bone(s) and muscle(s)/ tendon(s) of four  
of the following six areas: 1) head and neck; 2) spine, ribs and 
pelvis; 3) right upper extremity; 4) left upper extremity; 5) right 
lower extremity; and 6) left lower extremity. The examination of a 
given area includes: 

  • Inspection, percussion and/or palpation with notation of any misalignment, 
    asymmetry, crepitation, defects, tenderness, masses or effusions 
  • Assessment of range of motion with notation of any pain (eg, straight leg 
    raising), crepitation or contracture 
  • Assessment of stability with notation of any dislocation (luxation), 
    subluxation or laxity 
  • Assessment of muscle strength and tone (eg, flaccid, cogwheel, spastic) 
    with notation of any atrophy or abnormal movements 

Note: For the comprehensive level of examination, all four of the elements identified by a bullet must be performed and documented for each of four anatomic areas. For the three lower levels of examination, each element is counted separately for each body area. For example, assessing range of motion in two extremities constitutes two elements.

Extremities

[See musculoskeletal and skin]

Skin

  • Inspection and/or palpation of skin and subcutaneous tissue (eg, scars, rashes, lesions, cafe-au-lait spots, ulcers) in four of the following six areas: 1) head and neck; 2) trunk; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity.

Note: For the comprehensive level, the examination of all four anatomic areas must be performed and documented. For the three lower levels of examination,each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of two extremitites constitutes two elements.

Neurological/

Psychiatric
  • Test coordination (eg, finger/nose, heel/ knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)
  • Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes (eg, Babinski)
  • Examination of sensation (eg, by touch, pin, vibration, proprioception) 

Brief assessment of mental status including: 

  • Orientation to time, place and person
  • Mood and affect (eg, depression, anxiety, agitation) 
Content and Documentation Requirements
Level of Exam  Perform and Document:
Problem Focused  One to five elements identified by a bullet.
Expanded Problem Focused At least six elements identified by a bullet.
Detailed At least twelve elements identified by a bullet.
Comprehensive Perform all elements identified by a bullet; document 
every element in a box with a shaded border and at 
least one element in a box with an unshaded border.
h. Neurological Examination

System/Body Area 

Elements of Examination

Constitutional

  • Measurement of any three of the following seven vital signs:1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
  • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Head and Face

 

Eyes

  • Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, xudates, hemorrhages)

Ears, Nose,

Mouth and Throat
 

Neck

 

Respiratory

 

Cardiovascular

  • Examination of carotid arteries (eg, pulse amplitude, bruits)
  • Auscultation of heart with notation of abnormal sounds and murmurs
  • Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

 

Gastrointestinal 

(Abdomen)
 

Genitourinary

 

Lymphatic

 

Musculoskeletal

  • Examination of gait and station
    Assessment of motor function including: 
  • Muscle strength in upper and lower extremities 
  • Muscle tone in upper and lower extremities (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements (eg, fasciculation, tardive dyskinesia) 

Extremities

[See musculoskeletal]

Skin

 

Neurological

Evaluation of higher integrative functions including: 

  • Orientation to time, place and person 
  • Recent and remote memory 
  • Attention span and concentration 
  • Language (eg, naming objects, repeating phrases, spontaneous speech) 
  • Fund of knowledge (eg, awareness of current events, past, history, vocabulary) 

    Test the following cranial nerves: 

  • 2nd cranial nerve (eg, visual acuity, visual fields, fundi) 
  • 3rd, 4th and 6th cranial nerves (eg, pupils, eye movements) 
  • 5th cranial nerve (eg, facial sensation, corneal reflexes) 
  • 7th cranial nerve (eg, facial symmetry, strength) 
  • 8th cranial nerve (eg, hearing with tuning fork, whispered voice and/or finger rub) 
  • 9th cranial nerve (eg, spontaneous or reflex palate movement) 
  • 11th cranial nerve (eg, shoulder shrug strength) 
  • 12th cranial nerve (eg, tongue protrusion) 
  • Examination of sensation (eg, by touch, pin, vibration, proprioception)
  • Examination of deep tendon reflexes in upper and lower extremities with notation of pathological reflexes (eg, Babinski)
  • Test coordination (eg, finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)

Psychiatric

 
Content and Documentation Requirements
Level of Exam  Perform and Document:
Problem Focused  One to five elements identified by a bullet.
Expanded Problem Focused At least six elements identified by a bullet.
Detailed At least twelve elements identified by a bullet.
Comprehensive Perform all elements identified by a bullet; document 
every element in a box with a shaded border and at least 
one element in a box with an unshaded border.
i. Psychiatric Examination

System/Body Area 

Elements of Examination

Constitutional

  • Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)

    General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Head and Face

 

Eyes

 

Ears, Nose, Mouth 

and Throat
 

Neck

 

Respiratory

 

Cardiovascular

 

Chest (Breasts)

 

Gastrointestinal 

(Abdomen)
 

Genitourinary

 

Lymphatic

 

Musculoskeletal

  • Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements
  • Examination of gait and station

Extremities

 

Skin

 

Neurological

 

Psychiatric

  • Description of speech including: rate; volume; articulation; coherence;and spontaneity with notation of abnormalities (eg, perseveration, paucity of language) 
  • Description of thought processes including: rate of thoughts; content of thoughts (eg, logical vs. illogical, tangential); abstract reasoning; and computation) 
  • Description of associations (eg, loose, tangential, circumstantial, intact)
  • Description of abnormal or psychotic thoughts including: hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions
  • Description of the patient's judgment (eg, concerning everyday activities and social situations) and insight (eg, concerning psychiatric condition) 

Complete mental status examination including: 

  • Orientation to time, place and person 
  • Recent and remote memory 
  • Attention span and concentration 
  • Language (eg, naming objects, repeating phrases) 
  • Fund of knowledge (eg, awareness of current events, past history, vocabulary) 
  • Mood and affect (eg, depression, anxiety, agitation, hypomania, lability) 
Content and Documentation Requirements
Level of Exam  Perform and Document:
Problem Focused  One to five elements identified by a bullet.
Expanded Problem Focused At least six elements identified by a bullet.
Detailed  At least nine elements identified by a bullet.
Comprehensive Perform all elements identified by a bullet; document 
every element in a box with a shaded border and at least 
one element in a box with an unshaded border.
j. Respiratory Examination

System/Body Area 

Elements of Examination

Constitutional

  • Measurement of any three of the following seven vital signs: 
    1) sitting or standing blood pressure, 2) supine blood pressure, 
    3) pulse rate and regularity, 4) respiration, 5) temperature, 
    6) height, 7) weight (May be measured and recorded by ancillary staff) 
  • General appearance of patient (eg, development, nutrition, body habitus,deformities, attention to grooming)

Head and Face

 

Eyes

 

Ears, Nose,

Mouth and Throat
  • Inspection of nasal mucosa, septum and turbinates
  • Inspection of teeth and gums 
  • Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils and posterior pharynx)

Neck

  • Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)
  • Examination of thyroid (eg, enlargement, tenderness, mass)
  • Examination of jugular veins (eg, distension; a, v or cannon a waves)

Respiratory

  • Inspection of chest with notation of symmetry and expansion 
  • Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)
  • Percussion of chest (eg, dullness, flatness, hyperresonance)
  • Palpation of chest (eg, tactile fremitus) 
  • Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

  • Auscultation of heart including sounds, abnormal sounds and murmurs
  • Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

 

Gastrointestinal

(Abdomen)
  • Examination of abdomen with notation of presence of masses or tenderness 
  • Examination of liver and spleen

Genitourinary

 

Lymphatic

  • Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal

  • Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements
  • Examination of gait and station

Extremities

  • Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)

Skin

  • Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)

Neurological/

Psychiatric

Brief assessment of mental status including: 

  • Orientation to time, place and person 
  • Mood and affect (eg, depression, anxiety, agitation) 
Content and Documentation Requirements
Level of Exam  Perform and Document:
Problem Focused  One to five elements identified by a bullet.
Expanded Problem Focused At least six elements identified by a bullet.
Detailed At least twelve elements identified by a bullet.
Comprehensive Perform all elements identified by a bullet; document 
every element in a box with a shaded border and at least 
one element in a box with an unshaded border.
k. Skin Examination

System/Body Area 

Elements of Examination

Constitutional

  • Measurement of any three of the following seven vital signs: 
    1) sitting or standing blood pressure, 2) supine blood pressure, 
    3) pulse rate and regularity, 4) respiration, 5) temperature, 
    6) height, 7) weight (May be measured and recorded by ancillary staff) 
  • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Head and Face

 

Eyes

  • Inspection of conjunctivae and lids

Ears, Nose,

Mouth and Throat
  • Inspection of lips, teeth and gums 
  • Examination of oropharynx (eg,oral mucosa, hard and soft palates, tongue, tonsils, posterior pharynx)

Neck

  • Examination of thyroid (eg, enlargement, tenderness, mass)

Respiratory

 

Cardiovascular

  • Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

 

Gastrointestinal

(Abdomen)
  • Examination of liver and spleen 
  • Examination of anus for condyloma and other lesions

Genitourinary

 

Lymphatic

  • Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal

 

Extremities

  • Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)

Skin

  • Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities 
  • Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas:  1) head, including the face and 2) neck; 3) chest, including breasts and axillae; 4) abdomen; 5) genitalia, groin, buttocks; 6) back; 7) right upper extremity; 8) left upper extremity; 9) right lower extremity; 10) left lower extremity

Note: For the comprehensive level, the examination of at least eight anatomic areas must be performed and documented. For the three lower levels of examination,each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of the right upper extremity and the left upper extremity constitutes two elements.  

  • Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis. 

Neurological/

Psychiatric

Brief assessment of mental status including: 

  • Orientation to time, place and person 
  • Mood and affect (eg, depression, anxiety, agitation) 
Content and Documentation Requirements
Level of Exam  Perform and Document:
Problem Focused  One to five elements identified by a bullet.
Expanded Problem Focused At least six elements identified by a bullet.
Detailed At least twelve elements identified by a bullet.
Comprehensive Perform all elements identified by a bullet; document 
every element in a box with a shaded border and at least 
one element in a box with an unshaded border.
l. Documentation of the Complexity of Medical Decision Making

The levels of E/M services recognize four types of medical decision making (straight-forward, low complexity, moderate complexity and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.

Number of diagnoses

or management options

Amount and/or complexity

of data to be reviewed

Risk of complications

and/or morbidity or mortality

Type of decision making

Minimal Minimal or None Minimal Straightforward
Limited Limited Low Low Complexity
Multiple Moderate Moderate Moderate Complexity
Extensive Extensive High High Complexity
l.1 Number of Diagnoses or Management Options

The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.

Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems.

  • DG: For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.

l.2 Amount and/or Complexity of Data to be Reviewed

The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed.

Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test is an indication of the complexity of data being reviewed. On occasion the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or interpretation; this is another indication of the complexity of data being reviewed.

 

l.3 Risk of Significant Complications, Morbidity, and/or Mortality

The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.

The following table may be used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.

m Table of Risk

Table Of Risk

Level of Risk

Presenting Problem(s)

Diagnostic Procedure(s)

Management Options

Selected

Minimal

  • One self-limited or minor problem, eg cold, insect bite, tinea corporis 
  • Laboratory tests requiring venipuncture 
  • Chest x-ray 
  • EKG/EEG 
  • Urinalysis 
  • Ultrasound, eg, echocardiography 
  • KOH prep 
  • Rest 
  • Gargles 
  • Elastic bandages 
  • Superficial dressings 

 

Low

  • Two or more self limited or minor problems 
  • One stable chronic illness, eg well controlled hypertension or non- insulin dependent diabetes, cataract, BPH 
  • Acute uncomplicated illness or injury, eg cystitis, allergic rhinitis, simple sprain 

 

  • Physiologic tests not under stress, eg, pulmonary function tests 
  • Non-cardiovascular imaging studies with contrast, eg, barium enema 
  • Superficial needle biopsies 
  • Clinical laboratory tests requiring arterial puncture 
  • Skin biopsies 

 

  • Over-the-cunter drugs 
  • Minor surgery with no identified risk factors 
  • Physical therapy 
  • Occupational therapy 
  • IV fluids without additives 

 

Moderate

  • One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment 
  • Two or more stable chronic illnesses 
  • Undiagnosed new problem with uncertain prognosis, eg, lump in breast 
  • Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis 
  • Acute complicated injury, eg head injury with brief loss of consciousness 

 

  • Physiologic tests under stress, eg cardiac stress test, fetal contraction stress test 
  • Diagnostic endoscopies with no identified risk factors 
  • Deep needle or incisional biopsy 
  • Cardiovascular imaging studies with contrast and no identified risk factors, eg arteriogram, cardiac catheterization 
  • Obtain fluid from body cavity, eg lumbar puncture, thoracentesis, culdocentesis 

 

  • Minor surgery with identified risk factors 
  • Elective major surgery (open, percutaneous or endoscopic) with not identifed risk factors 
  • Prescription drug management 
  • Therapeutic nuclear medicine 
  • IV fluids with additives 
  • Closed treatment of fracture or dislocation without manipulation 

 

High

  • One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment 
  • Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, eg multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or other, peritonitis, acute renal failure 
  • An abrupt change in neurologic status, eg seizure, TIA, weakness, or sensory loss 

 

  • Cardiovascular imaging studies with contrast with identified risk factors 
  • Cardiac electrophysiological tests 
  • Diagnostic Endoscopies with identified risk factors 
  • Discography 

 

  • Elective major surgery (open, percutaneous or endoscopic) with identified risk factors 
  • Emergency major surgery (open, percutaneous or endoscopic) 
  • Parenteral controlled substances 
  • Drug therapy requiring intensive monitoring for toxicity 
  • Decision not to resuscitate or to de-esculate care because of poor prognosis 

 

 
n. Documentation of an Encounter Dominated by Counseling or Coordination of Care

In the case where counseling and/or coordination of care dominates more than 50% of the physician/patient and/or family encounter (face-to-face time in the office or other or outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.