Introduction and Definitions

The purpose of this tutorial (and of this entire website) is to provide physicians with the tools they need to educate themselves about E/M coding and documentation.  The fundamental principle of E/M University is that knowledge is power when it comes to E/M coding and documentation.  Too many physicians are chronically undercoding for their services because they don’t understand the rules.  A working knowledge of the E/M coding is the best way to ensure optimal compliance and avoid inadvertent undercoding.   Physicians who are facile with the idiosyncratic process of E/M documentation can command a higher rate of return on their cognitive labor than their less E/M-savvy counterparts.  In other words if you know how to accurately bill for your services, there is a better chance you will get paid for what you really do.

E/M stands for “evaluation and management”.  E/M coding is the process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing.  CPT stands for “current procedural terminology.” These are the numeric codes which are submitted to insurers for payment.  Every billable procedure has its own individual CPT code.  

The CPT codes which describe physician-patient encounters are often referred to as “E/M codes”   There are different E/M codes for different types of encounters such as office visits or hospital visits.  Within each type of encounter, there are different levels of care.  For example, the 99214 code may be used to charge for an office visit with an established patient.  There are five levels of care for this type of encounter.  The 99214 code is often called a “level 4” office visit because the code ends in a “4” and also because it is the fourth “level of care” for that type of visit (with the 99215 being the fifth and highest level of care).  Each patient care encounter may be viewed as a unique procedure which requires specific documentation. 

The Key Components of E/M Documentation

The documentation for E/M services is based on three “key” components:

1. History
2. Physical Exam
3. Medical Decision-Making

E/M University Coding Tip: The key components are used to satisfy the documentation requirements for E/M coding UNLESS the physician is coding based on TIME.  If time is the controlling factor, there are no specific documentation requirements for the three key components.

 The E/M key components can be thought of as the building blocks of documentation for all patient encounters.  Some types of encounters require complete documentation of all three key components, while others require only two out of three.

 The E/M Guidelines

The documentation requirements for each individual E/M code are dictated by a set of rules called the E/M guidelines.  The E/M guidelines were developed by the Center for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association.  Two versions have been released—the first in 1995 and the last in 1997.  

The Complete 1995 and 1997 E/M guidelines may be downloaded by clicking here.

For a more detailed discussion about which version may be best for you,  click here.

The E/M guidelines define the requirements for individual E/M codes based on the extent of the documentation of the three key components. In general, higher paying E/M codes (like consultations or initial office visits) require more extensive documentation than lower paying codes (such as office visits with established patients or hospital progress notes).  

E/M University Coding Tip:The physician MUST choose to use EITHER the 1995 OR the 1997 E/M guidelines.  It is NOT acceptable to mix and match elements from both sets of rules within the body of the same note.

E/M University Coding Tip: The 1995 and 1997 E/M guidelines are practically identical when it comes to the key components of history and Medical Decision-Making.  The main difference between the two versions lies in the documentation required for the physical exam (see 1995 Vs. 1997 E/M guidelines).

E/M University Coding Tip: Due to increased flexibility for recording the HPI, most physicians should use the 1997 E/M guidelines for encounters where the patient has no spontaneous somatic complaints. 

The E/M guidelines define the requirements for individual E/M codes based on the extent of the documentation of the three key components. In general, higher paying E/M codes (like consultations or initial office visits) require more extensive documentation than lower paying codes (such as office visits with established patients or hospital progress notes).  In order to understand E/M coding, it is first necessary to understand each of the individual key components which are explained in our tutorial.