Documentation of E&M Services

III.            DOCUMENTATION OF E/M SERVICES

This publication 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 publication, the reader should refer to CPT for the 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:

·  history;

·  examination;

·  medical decision making;

·  counseling;

·  coordination of care;

·  nature of presenting problem; and

·  time.

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.