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Codes and Documentation for Evaluation and Management …
294 Codes and Documentation for Evaluation and Management ServicesThe Evaluation and Management (E/M) Codes were introduced in the 1992 up-date to the fourth edition of Physicians Current Procedural Terminology (CPT).These Codes cover a broad range of services for patients in both inpatient andoutpatient settings. In 1995 and again in 1997, the Health Care Financing Ad-ministration (now the Centers for Medicare and Medicaid Services, or CMS)published Documentation guidelines to support the selection of appropriateE/M Codes for services provided to Medicare beneficiaries. The major differ-ence between the two sets of guidelines is that the 1997 set includes a single-sys-tem psychiatry examination (mental status examination) that can be fullysubstituted for the comprehensive, multisystem physical examination requiredby the 1995 guideline.
Codes and Documentation for Evaluation and Management Services 31 • Straightforward medical decision making • Low-complexity medical decision making • Moderate-complexity medical decision making • High-complexity medical decision making • E/M codes have three to five levels of service based on increasing amounts of work.
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