E/M interactive worksheet

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).

Patient

Guidelines Selection

Determining Level of E/M Services

(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.

Office or Other Outpatient Services
Hospital Inpatient, Observation, or Emergency Department Services
Nursing Facility Services
Domiciliary, Rest Home, or Custodial Care Services
Home Care Services

History

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).

Documentation Guidelines for Evaluation and Management Services 1995/1997
History level based on '95 Guidelines:
History level based on '97 Guidelines:

Examination: 1995 E/M Documentation Guidelines

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.

Body Area(s) or Organ System(s): Examination Types
Exam Level (95):

Examination: 1997 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.

Body Areas
Elements of examination may include:
  • Inspection of head and face
  • Palpation and/or percussion of face with notation of presence/absence of sinus tenderness
  • Examination of salivary glands
  • Assessment of facial strength
Elements of examination may include:
  • Inspection of neck
  • Examination of thyroid
Elements of examination may include:
  • Inspection of breasts
  • Palpation of breasts and axillae
Elements of examination may include:
  • Inspection of abdomen with notations of presence of masses or tenderness
  • Examination of liver and spleen
  • Examination for presence/absence of hernia
  • Examination of anus, perineum, and rectum (when indicated) with notations of sphincter tone and presence of hemorrhoids or rectal masses
Elements of examination for male patient may include:
  • Examination of scrotal contents
  • Examination of the penis
  • Digital rectal examination of prostate gland
Elements of examination for female patient may include a pelvic examination (with or without specimen collection for smears and cultures):
  • Inspection of external genitalia and vagina
  • Examination of urethra
  • Examination of bladder
  • Inspection of cervix
  • Examination of uterus
  • Examination of adnexa/parametria
Elements of examination may include:
  • Inspection of the back with notation of kyphosis or scoliosis
  • Examination of gait
  • Assessment of muscle strength and tone with notation of any atrophy and abnormal movements
Elements of examination may include:
  • Inspection and palpation of digits and nails






 Total Body Areas
Organ Systems
Elements of examination may include:
  • Measurement of any three of the following seven vital signs:
    1. Sitting or standing blood pressure
    2. Supine blood pressure
    3. Pulse rate and regularity
    4. Respiration
    5. Temperature
    6. Height
    7. Weight (may be measured and recorded by ancillary staff)
  • Inspection of patient\’s general appearance
Elements of examination may include:
  • Inspection of conjunctivae and lids
  • Examination of pupils and irises
  • Ophthalmoscopic examination of optic discs and posterior segments
Elements of examination may include:
  • External inspection of ears and nose
  • Otoscopic examination of external auditory canals and tympanic membranes
  • Assessment of hearing
  • Inspection of nasal mucosa, septum, and turbinates
  • Inspection of lips, teeth, and gums
  • Examination of oropharynx: Oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx
Elements of examination may include:
  • Palpation of heart
  • Auscultation of heart with notation of abnormal sounds and murmurs
  • Examination of carotid arteries
  • Examination of abdominal aorta
  • Examination of femoral arteries
  • Examination of pedal pulses
  • Examination of extremities for edema and/or varicosities
Elements of examination may include:
  • Assessment of respiratory effort
  • Percussion of chest
  • Palpation of chest
  • Auscultation of lungs
Elements of examination may include:
  • Examination of abdomen with notation of presence of masses or tenderness
  • Examination of liver and spleen
  • Examination for presence/absence of hernia
  • Examination of anus, perineum, and rectum (when indicated) with notations of sphincter tone and presence of hemorrhoids or rectal masses
  • Obtain stool sample for occult blood test (when indicated)
Elements of examination for male patient may include:
  • Examination of scrotal contents
  • Examination of the penis
  • Digital rectal examination of prostate gland
Elements of examination for female patientmay include a pelvic examination (with or without specimen collection for smears and cultures):
  • Inspection of external genitalia and vagina
  • Examination of urethra
  • Examination of bladder
  • Inspection of cervix
  • Examination of uterus
  • Examination of adnexa/parametria
Elements of examination may include:
  • Examination of gait and station
  • Inspection and/or palpation of digits and nails
Examination of joints, bones and muscles in one or more of the following six areas:
1) Head and neck
2) Spine, ribs, and pelvis
3) Right upper extremity
4) Left upper extremity
5) Right lower extremity
6) Left lower extremity
Examination of given area includes:
  • Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, or effusions
  • Assessment of range of motion with notation of any pain, crepitation, or contracture
  • Assessment of stability with notation of any luxation, subluxation, or laxity
  • Assessment of muscle strength and tone with notation of any atrophy or abnormal movements
Elements of examination may include:
  • Inspection of skin and subcutaneous tissue
  • Palpation of skin and subcutaneous tissue
Elements of examination may include:
  • Testing of cranial nerves with notation of any deficits
  • Examination of deep tendon reflexes with notation of pathological reflexes
  • Examination of sensation
Elements of examination may include:
  • Description of patient\’s judgment and insight
Brief assessment of mental status including:
  • Orientation to time, place and person
  • Recent and remote memory
  • Mood and affect
Elements of examination may include palpation of lymph nodes in two or more areas:
  • Neck
  • Axillae
  • Groin
  • Other
 Total Organ Systems
Single Organ System: Examination Types
Examination should include performance and documentation of 1-5 bulleted elements.
Examination should include performance and documentation of at least 6 bulleted elements.
Examination should include performance and documentation of at least 12 bulleted elements.
Exception: Eye and psychiatric examinations require only 9 bulleted elements.
Examination should include performance of ALL bulleted elements.
Note: Documentation of ALL bulleted elements contained within a box with a shaded border and at least 1 element in each box with an unshaded border is expected.
General Multi-System: Examination Types
Examination should include performance and documentation of 1-5 bulleted elements for one or more organ systems or body areas.
Examination should include performance and documentation of at least 6 bulleted elements for one or more organ systems or body areas.
Examination should include performance and documentation of at least 2 bulleted elements for at least six organ systems or body areas
OR
At least 12 bulleted elements for two or more organ systems/body areas.
Examination should include performance of ALL bulleted elements for at least nine organ systems or body areas unless specific directions limit examination content.
Note: Documentation of at least 2 bulleted elements for each area/system is expected.
Exam Level (97):

Medical Decision Making

Documentation Guidelines for Evaluation and Management Services 1995/1997
Medical decision making

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:

  • The number of possible diagnoses and/or the number of management options that must be considered by the examiner
  • The amount and complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed by the examiner.
  • The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s) ordered, and/or the possible management options selected by the examiner
Number of Diagnoses or Management Options

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.

Presenting Problem
Level of RiskPresenting Problem
Minimal
  • One self-limited or minor problem ( e.g., cold, insect bite)
Low
  • Two or more self-limited or minor problems
  • One stable chronic illness (e.g., well-controlled hypertension, non-insulin dependent diabetes)
  • One acute uncomplicated illness or injury (e.g., cystitis, sprain)
Moderate
  • One or more chronic illnesses with mild exacerbation, progression, or treatment side effects
  • Two or more stable chronic illnesses
  • Undiagnosed new problem with uncertain prognosis
  • Acute illness with systemic symptoms (e.g., pneumonitis, colitis)
  • Acute complicated injury (e.g., head injury with brief loss of consciousness)
High
  • One or more chronic illnesses with severe exacerbation, progression, or treatment side effects
  • Acute or chronic illnesses or injuries that may pose a threat to life or bodily function (e.g., pulmonary embolus, severe respiratory distress, psychiatric illness with potential threat to self or others)
  • An abrupt change in neurologic status (e.g., seizure, TIA, sensory loss)
Occurrences
Self-limited or minor problem(s) -- stable, improving, progressing as expected, or resolved
Established diagnosis or diagnoses -- stable, improving, or resolved
Established diagnosis or diagnoses -- inadequately-controlled, worsening, or failing to change as expected
New problem to examiner -- no diagnostic procedures ordered
New problem to examiner -- diagnostic procedure(s) ordered
Element Level: 0
Amount and/or Complexity of Data to Be Reviewed

Instructions: Place a checkmark next to any option that describes services performed and documented during the patient visit. Please select all that apply.

Element Level:
Risk of Significant Complications, Morbidity, and/or Mortality

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.

Presenting Problem
Level of RiskPresenting Problem
Minimal
  • One self-limited or minor problem ( e.g., cold, insect bite)
Low
  • Two or more self-limited or minor problems
  • One stable chronic illness (e.g., well-controlled hypertension, non-insulin dependent diabetes)
  • One acute uncomplicated illness or injury (e.g., cystitis, sprain)
Moderate
  • One or more chronic illnesses with mild exacerbation, progression, or treatment side effects
  • Two or more stable chronic illnesses
  • Undiagnosed new problem with uncertain prognosis
  • Acute illness with systemic symptoms (e.g., pneumonitis, colitis)
  • Acute complicated injury (e.g., head injury with brief loss of consciousness)
High
  • One or more chronic illnesses with severe exacerbation, progression, or treatment side effects
  • Acute or chronic illnesses or injuries that may pose a threat to life or bodily function (e.g., pulmonary embolus, severe respiratory distress, psychiatric illness with potential threat to self or others)
  • An abrupt change in neurologic status (e.g., seizure, TIA, sensory loss)
Diagnostic Procedure(s) Ordered
Level of RiskDiagnostic Procedure(s) Ordered
Minimal
  • Laboratory tests requiring venipuncture
  • Chest X-rays
  • EKG/EEG
  • Urinalysis
  • Ultrasound
  • KOH prep
Low
  • Physiologic tests not under stress (e.g., pulmonary function tests)
  • Non-cardiovascular imaging studies with contrast (e.g., barium enema)
  • Superficial needle biopsies
  • Clinical laboratory tests requiring arterial puncture
  • Skin biopsies
Moderate
  • Physiologic tests under stress (e.g., cardiac stress test, fetal contraction stress test)
  • Diagnostic endoscopies with no identified risk factors
  • Deep needle or incisional biopsy
  • Cardiovascular imaging studies with contrast AND no identified risk factors (e.g., arteriogram, cardiac catheterization)
  • Obtain fluid from body cavity (e.g., lumbar puncture, thoracentesis, culdocentesis)
High
  • Cardiovascular imaging studies with contrast AND with identified risk factors
  • Cardiac electrophysiological tests
  • Diagnostic Endoscopies with identified risk factors
  • Discography
Management Options Selected
Level of RiskManagement Options Selected
Minimal
  • Rest
  • Gargles
  • Elastic Bandages
  • Superficial dressings
Low
  • Over-the-counter drugs
  • Minor surgery with no identified risk factors
  • Physical therapy
  • Occupational therapy
  • IV fluids without additives
Moderate
  • Minor surgery with identified risk factors
  • Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors
  • Prescription drug management
  • Therapeutic nuclear medicine
  • IV fluids with additives
  • Closed treatment of fracture or dislocation without manipulation
High
  • Elective major surgery (open, percutaneous, or endoscopic) with identified risk factors
  • Emergency major surgery (open, percutaneous, or endoscopic)
  • Parenteral controlled substances
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision not to resuscitate or to de-escalate care because of poor prognosis
  • One self-limited or minor problem ( e.g., cold, insect bite)
  • Laboratory tests requiring venipuncture
  • Chest X-rays
  • EKG/EEG
  • Urinalysis
  • Ultrasound
  • KOH prep
  • Rest
  • Gargles
  • Elastic Bandages
  • Superficial dressings
  • Two or more self-limited or minor problems
  • One stable chronic illness (e.g., well-controlled hypertension, non-insulin dependent diabetes)
  • One acute uncomplicated illness or injury (e.g., cystitis, sprain)
  • Physiologic tests not under stress (e.g., pulmonary function tests)
  • Non-cardiovascular imaging studies with contrast (e.g., barium enema)
  • Superficial needle biopsies
  • Clinical laboratory tests requiring arterial puncture
  • Skin biopsies
  • Over-the-counter drugs
  • Minor surgery with no identified risk factors
  • Physical therapy
  • Occupational therapy
  • IV fluids without additives
  • One or more chronic illnesses with mild exacerbation, progression, or treatment side effects
  • Two or more stable chronic illnesses
  • Undiagnosed new problem with uncertain prognosis
  • Acute illness with systemic symptoms (e.g., pneumonitis, colitis)
  • Acute complicated injury (e.g., head injury with brief loss of consciousness)
  • Physiologic tests under stress (e.g., cardiac stress test, fetal contraction stress test)
  • Diagnostic endoscopies with no identified risk factors
  • Deep needle or incisional biopsy
  • Cardiovascular imaging studies with contrast AND no identified risk factors (e.g., arteriogram, cardiac catheterization)
  • Obtain fluid from body cavity (e.g., lumbar puncture, thoracentesis, culdocentesis)
  • Minor surgery with identified risk factors
  • Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors
  • Prescription drug management
  • Therapeutic nuclear medicine
  • IV fluids with additives
  • Closed treatment of fracture or dislocation without manipulation
  • One or more chronic illnesses with severe exacerbation, progression, or treatment side effects
  • Acute or chronic illnesses or injuries that may pose a threat to life or bodily function (e.g., pulmonary embolus, severe respiratory distress, psychiatric illness with potential threat to self or others)
  • An abrupt change in neurologic status (e.g., seizure, TIA, sensory loss)
  • Cardiovascular imaging studies with contrast AND with identified risk factors
  • Cardiac electrophysiological tests
  • Diagnostic Endoscopies with identified risk factors
  • Discography
  • Elective major surgery (open, percutaneous, or endoscopic) with identified risk factors
  • Emergency major surgery (open, percutaneous, or endoscopic)
  • Parenteral controlled substances
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision not to resuscitate or to de-escalate care because of poor prognosis
Level of Decision Making based on '95 or '97 Guidelines:
Do any of the following apply to the service you just scored?