Evaluation and Management Services

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ICN 006764 January 2020Page 1 of 23BOOKLETEVALUATION AND Management Services GUIDEPRINT-FRIENDLY VERSIONCPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/HHSAR Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical Services . The AMA assumes no liability for data contained or not contained Audience: Medicare Fee-For-Service ProvidersNOTE: The Hyperlink Table, at the end of this document, provides the complete URL for each BookletEvaluation and Management Services GuideICN 006764 January 2020Page 2 of 23TABLE OF CONTENTSPREFACE3MEDICAL RECORD DOCUMENTATION 4GENERAL PRINCIPLES OF E/M DOCUMENTATION 4COMMON SETS OF CODES USED TO BILL FOR E/M Services 5HCPCS5International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) 6E/M Services PROVIDERS 6SELECTING THE CODE THAT BEST REPRESENTS THE SERVICE FURNISHED 6Patient Type 6Setting of Service 6Level of E/M Service Performed 7History7Elements Required for Each Type of History 7Chief Complaint (CC) 7History of Present Ill

1995 Documentation Guidelines for Evaluation and Management Services and the 1997 Documentation Guidelines for Evaluation and Management Services.

  Services, Management, Evaluation, Evaluation and management services