Evaluation and management (E/M) services refer to visits furnished by physicians. Billing Medicare for a patient visit requires the selection of the code that best represents the level of E/M service performed. The purpose of this interactive worksheet is to assist providers with identifying the appropriate E/M code based upon either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services.
Since the 1995 and 1997 guidelines each specify different criteria to determine the level of E/M service performed, only one set of guidelines may be used to document a specific patient visit. This interactive worksheet offers providers the option to select either their preferred set of guidelines (1995 or 1997) or to select both for the purpose of comparison. To learn more about the interactive features of this E/M resource, please refer to the E/M interactive worksheet: Help guide and E/M interactive worksheet FAQs.
Note: This interactive worksheet was created as a tool to assist providers and is not intended as a replacement for the 1995 and 1997 E/M documentation guidelines published by the Centers for Medicare & Medicaid Services (CMS).
(Performance and documentation requirements for key components: History, Examination, and Medical Decision Making)
Instructions: Please make your selection based upon your place of service, whether the patient is new or established, the description that best characterizes the nature of the visit, and the number of key components documented.
The extent of history of present illness (HPI), review of systems (ROS), and past, family, and/or social history (PFSH) obtained and documented is dependent upon clinical judgment and the nature of the patient’s presenting problem(s).
Note: For patient visits requiring an “interval history�? (e.g., subsequent hospital, nursing care) a ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded; however, the review of the information should be documented by indicating its status (i.e., description of change(s)/no change to information).
An examination may involve a single organ system or several. The extent of the examination performed is dependent upon the examiner’s clinical judgment, the patient’s history, and the nature of the presenting problem. Types of examination range from limited examinations of a single body area to general multi-system or complete single organ system examinations.
When making each selection, use your cursor to reveal helpful E/M tooltips. For additional guidance, please refer to the 1995 E/M Documentation Guidelines.
When making each selection, use your cursor to reveal helpful E/M tooltips that are based upon general multi-system examination requirements. Please refer to the tables contained within the 1997 E/M Documentation Guidelines for specific content criteria for single organ system examinations -- including bullet and shaded/unshaded border specifications -- as well as individual examination elements of the applicable body area or system.
Medical decision making refers to the level of complexity associated with establishing a diagnosis and/or selecting a management option. The level of complexity is measured by the following factors:
Instructions: For each of the qualifying elements listed below, please enter the number of occurrences that match the criteria specified within the element. For additional guidance, please refer to either the 1995 or 1997 E/M documentation guidelines.
Instructions: Place a checkmark next to any option that describes services performed and documented during the patient visit. Please select all that apply.
Instructions: Because the determination of risk is complex and not readily quantifiable, helpful E/M tooltips have been created to assist you. To reveal each tooltip, place your cursor over each category heading and level selection to display the applicable section of the Table of Risk included within the 1995 and 1997 E/M documentation guidelines.