Visit (E&M) coding

by Mark Morgan on September 22, 2011

in General

Tagged as: , ,

summary, references, & relevant links
Interactive calculator to determine correct Evaluation and Management Services (E and M) Code for a New or Established Office Visit. Based on the 1997 Centers for Medicare and Medicaid Services Guidelines. More information at the CMS website.
More on coding can be found at Family Practice Management Hill (2011) Fam Pract Manag 18:33-38.

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BEGIN: There are two calculators, one for new visits and one for established visits. Click on the appropriate link below to select which calculator.

CHOOSE: New Visit or Established Visit

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New Visit

  • There are three sections: History, Examination, and Medical Decision Making. For a new visit, the lowest scoring section determines the level.
    (maintained at soapnote.org.)
  • Section 1: History
    Notes:
    A documented chief complaint is mandatory to bill above 99201.
    For the history section, the lowest level of the three subsections determines the billing level.
    elements: Location (example: left leg); Quality (example: aching, burning, radiating pain); Severity (example: 10 on a scale of 1 to 10); Duration (example: started three days ago); Timing (example: constant or comes and goes); Context (example: lifted large object at work); Modifying factors (example: better when heat is applied); and Associated signs and symptoms (example: numbness in toes).
    elements: Constitutional symptoms (e.g., fever, weight loss); Eyes; Ears, Nose, Mouth, Throat; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeletal; Integumentary (skin and/or breast); Neurological; Psychiatric; Endocrine; Hematologic/Lymphatic; and Allergic/Immunologic
    Elements: Past medical history, Family history, Social history
  • Section 2: Examination
  • CMS Table of examination elements
    elements are bulleted under these organ systems: Cardiovascular; Ears, Nose, Mouth and Throat; Eyes; Genitourinary (Female); Genitourinary (Male); Hematologic/Lymphatic/Immunologic; Musculoskeletal; Neurological; Psychiatric; Respiratory; and Skin
  • Section 3: Medical Decision Making
    Notes:
    For decision making section, the second highest (or median) level of the three subsections determines the billing level.
    guide: 1 diagnosis or management option = Minimal, 2 = Limited, 3 = Multiple, 4 = Extensive
    number of diagnostic tests ordered or reviewed
  • CMS Info on Decision Making Risk Download the CMS E&M Guide

Result - Paste this into your EHR:

Established Visit

  • There are three sections: History, Examination, and Medical Decision Making. For an established visit, the two highest scoring sections are used to determine the level.
    maintained at soapnote.org.
  • Section 1: History
    Notes:
    A documented chief complaint is mandatory to bill above 99211.
    For the history section, the lowest level of the three subsections determines the billing level.
    elements: Location (example: left leg); Quality (example: aching, burning, radiating pain); Severity (example: 10 on a scale of 1 to 10); Duration (example: started three days ago); Timing (example: constant or comes and goes); Context (example: lifted large object at work); Modifying factors (example: better when heat is applied); and Associated signs and symptoms (example: numbness in toes).
    elements: Constitutional symptoms (e.g., fever, weight loss); Eyes; Ears, Nose, Mouth, Throat; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeletal; Integumentary (skin and/or breast); Neurological; Psychiatric; Endocrine; Hematologic/Lymphatic; and Allergic/Immunologic
    Elements: Past medical history, Family history, Social history
  • Section 2: Examination
  • CMS Table of examination elements
    elements are bulleted under these organ systems: Cardiovascular; Ears, Nose, Mouth and Throat; Eyes; Genitourinary (Female); Genitourinary (Male); Hematologic/Lymphatic/Immunologic; Musculoskeletal; Neurological; Psychiatric; Respiratory; and Skin
  • Section 3: Medical Decision Making Notes:
    For the decision making section, the second highest (or median) level of the three subsections determines the billing level.
    guide: 1 diagnosis or management option = Minimal, 2 = Limited, 3 = Multiple, 4 = Extensive
    number of diagnostic tests ordered or reviewed
  • CMS Info on Decision Making Risk Download the CMS E&M Guide

Result - Paste this into your EHR:

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