E&M Coder Section

athenaClinicals

The optional E&M coder uses athenaOne logic and data licensed from Medicomp to calculate a suggested E&M code for an encounter.

Disclaimer: This tool is intended for reference only. Users of the E&M coder must have an expert understanding of the E&M coding guidelines. The intended use of this tool is for you to validate your E&M code selection.

 

20.11 update: In 2021, the AMA and CMS are simplifying and clarifying the guidelines for billing evaluation and management (E&M) office visits and other outpatient services, which affects codes 99201–99215. To reflect these changes, we're updating the E&M coder. See the 2021 E&M coder guidelines section of this page for more details.

 

Important: To help you prepare for these changes, you can preview the updates to the E&M coder, but you're only able to complete the workflow for encounters that are scheduled to occur on or after January 1, 2021.

 

Providers:

In the Sign-off stage of the encounter, click the Billing tab, then click E&M Coder.

Administrative staff:

On the Claim: Billing tab in the Checkout stage, scroll down to the Services section to see confirmation of the E&M coder calculation.

 

 

To use the E&M coder, contact the CSC by selecting Support > Create Case or Call in the Main Menu and request that the E&M Coder feature be enabled for your practice.

 

 

 

Evaluation and Management (E&M) codes are represented as CPT 99201-99499. They are the most controversial subset of CPT codes, and they represent a significant portion of revenue for most providers. E&M code derivation is a complicated process based on multiple subjective interpretations. Because of this elaborate calculation process, most providers have little confidence that they are coding correctly.

 

The E&M coder logic

The E&M coder section uses logic and data licensed from a third party, Medicomp. Medicomp is a commercial provider of clinical terminology for electronic medical records. Medicomp terminology products include a variety of vocabularies for describing clinical information. Not all elements of an E&M code can be prepopulated in athenaClinicals.

Note: The athenaOne E&M coder tool relays information to Medicomp and retrieves the Medicomp suggested code. The athenaOne tool does not assess this information to suggest an E&M code for the visit.

 

Medicomp Terms of Use

Before using the E&M coder, your practice must agree to the terms of use set forth by Medicomp. Per our contract with Medicomp, athenahealth is required to prompt each user to accept the Medicomp terms of use at these intervals:

  • First time that the user accesses the E&M coder
  • 6 days following the first time that the user accessed the E&M coder
  • On the anniversary that the user first accessed the E&M coder

When prompted, click the I have read and understand these terms button.

 

 

 

The athenaOne E&M coder tool collects data during each stage of an encounter, then uses logic and data licensed from Medicomp to calculate a suggested code.

  1. The athenaOne encounter interface collects information about the encounter through templates.
  2. The information is passed to the Medicomp E&M engine, where it is evaluated and a suggested code is determined.
  3. Medicomp sends the suggested code back to athenaOne, where it is displayed in the E&M coder tool and prepopulates the billing tab.

The more comprehensive the encounter, the more comprehensive the resultant code. The E&M code is based on all sections of the encounter; if any section is missing, the information from that section is not used in determining the code.

 

Medicomp uses MEDCIN IDs to determine an E&M code. To ensure the maximum use of encounter information, it is helpful to use global templates because global templates include the MEDCIN ID for findings. You can see which findings in your templates have MEDCIN IDs by opening and editing the template. An asterisk (*) next to a finding indicates a non-MEDCIN finding, which will not factor into determining the code.

 

 

 

To reduce administrative burden and improve consistency among payers, the AMA has simplified and clarified the CPT E/M guidelines for office visits and other outpatient services, and the CMS has proposed adopting these guidelines, beginning on January 1, 2021. Select 2021 - Medical Decision Making as the Type of exam to see 2021 updates.

 

Physicians can choose to follow the AMA CPT E/M guidelines for 2021 or to continue using the CMS 1995 or 1997 guidelines.

 

Although athenaOne collects data during each stage of the encounter and automatically completes some fields in the E&M coder, this data is no longer needed according to the 2021 guidelines. Therefore, these fields are disabled when you select 2021 - Medical Decision Making as the Type of exam.

 

 

If you choose to follow the 2021 guidelines, you can calculate an E&M code based on time or MDM.

 

Note: If you select Bill by time? and complete the Total Time field and the fields in the Complexity of Medical Decision Making section, athenaOne calculates two E&M codes — one based on time and one based on MDM — and then suggests the more complex E&M code.

 

What types of activities can count toward the total time?

According to the AMA's updated CPT E/M guidelines, you can include the following time spent by the physician and other qualified health care professionals on the day of the encounter:

  • Face-to-face time with the patient
  • Preparing to see the patient (for example, reviewing tests)
  • Obtaining and reviewing separately obtained history
  • Performing a medically appropriate examination or evaluation
  • Counseling and educating the patient, family, or caregiver
  • Ordering medications, tests, or procedures
  • Referring and communicating with other health care professionals (when not separately reported)
  • Documenting clinical information in the electronic or other health record
  • Independently interpreting results (not separately reported) and communicating results to the patient, family, or caregiver
  • Care coordination (not separately reported)

 

 

Note: If you choose to follow the 2021 guidelines, time refers to the total time that the physician and other qualified health care professionals spent on the day of the encounter. This time isn't limited to time spent face-to-face with the patient and may, for example, include time spent preparing to see the patient and coordinating care.

  1. Display the E&M coder:

    • Providers: In the Sign-off stage of the encounter, click the Billing tab, and then click E&M Coder.

    • Administrative staff: On the Claim: Billing tab in the Checkout stage, scroll down to the Services section to see confirmation of the E&M coder calculation.
  2. Complete the fields in the Exam Information section. 
  3. Type of Exam — Select 2021 - Medical Decision Making.
  4. Select Bill by time?.
  5. Total Time — Enter the minutes that the physician and other qualified health care professionals spent on the day of the encounter into the field.
  6. Click Calculate.
    athenaOne displays the suggested code above the Note field.

 

  1. Display the E&M coder:

    • Providers: In the Sign-off stage of the encounter, click the Billing tab, and then click E&M Coder.

    • Administrative staff: On the Claim: Billing tab in the Checkout stage, scroll down to the Services section to see confirmation of the E&M coder calculation.
  2. Complete the fields in the Exam Information section.
  3. Type of Exam — Select 2021 - Medical Decision Making.
  4. Complete the fields in the Complexity of Medical Decision Making section.
    Important: The AMA has modified the criteria for MDM. Before selecting an option, click the information icon to view the revised and clarified definitions. You can refer to the CPT E/M Office Revisions Level of Medical Decision Making (MDM) table from the AMA to help you determine the appropriate level of MDM.
  5. Click Calculate.
    athenaOne displays the suggested code above the Note field.

 

 

 

For more information, see:

 

 

 

Factors that are used to determine the E&M code are as follows:

  • The level of History
    • 1 = Problem focused
    • 2 = Expanded problem focused
    • 3 = Detailed
    • 4 = Comprehensive
  • The level of Physical Examination
    • 1 = Problem Focused
    • 2 = Expanded Problem Focused
    • 3 = Detailed
    • 4 = Comprehensive
  • The level of Medical Decision Making
    • 1 = Straightforward
    • 2 = Low complexity
    • 3 = Moderate complexity
    • 4 = High complexity
  • The type of setting: The place of service as indicated by the service department.
  • The type of service provided: One of the codes in the set of records from the qualifier table having the code name SERVICE. Note that only specific services are valid for a given setting. These are easily determined as follows: Services valid for a setting include those where the first character of the service code matches the setting code, or where the service code begins with "A" or "B." This list appears in the "Evaluation and Management Code Table" section.
  • The patient status: New or Established.
  • The total time spent with the patient: The total time in minutes spent with the patient. This includes the time in which the physician performs such tasks as obtaining a history, performing an examination, and counseling the patient. This time entry is important for those E&M codes that rely specifically on time (for example, Hospital discharge services — Final discharge). Whether this time spent exceeds 50% of the total time is also relevant.

Note: The "Evaluation and Management Code Table" section lists each CPT code and what combination of factors is required for the assignment of that code.

 

 

 

Given a type of service and patient status in an outpatient setting, either time requirements or documentation requirements may justify the code. Where time time is specified, the time spent counseling the patient must also be over half the encounter time.

 

Type of Service Patient Status Total Time Alternative Required History, Exam, and Medical Decision Making Elements Required History, Exam, and Medical Decision Making Levels Calculated Code
Outpatient Visit New 20 ALL 3 HIST2, EXAM2, MDM1 99202
Outpatient Visit New 30 ALL 3 HIST3, EXAM3, MDM2 99203
Outpatient Visit New 45 ALL 3 HIST4, EXAM4, MDM3 99204
Outpatient Visit New 60 ALL 3 HIST4, EXAM4, MDM4 99205
Outpatient Visit Est. 5 2 OF 3 PRES PROB MIN- NON-DOC OK 99211
Outpatient Visit Est. 10 2 OF 3 HIST1, EXAM1, MDM1 99212
Outpatient Visit Est. 15 2 OF 3 HIST2, EXAM2, MDM2 99213
Outpatient Visit Est. 25 2 OF 3 HIST3, EXAM3, MDM3 99214
Outpatient Visit Est. 40 2 OF 3 HIST4, EXAM4, MDM4 99215
Outpatient Consult N/E 15 ALL 3 HIST1, EXAM1, MDM1 99241
Outpatient Consult N/E 30 ALL 3 HIST2, EXAM2, MDM1 99242
Outpatient Consult N/E 40 ALL 3 HIST3, EXAM3, MDM2 99243
Outpatient Consult N/E 60 ALL 3 HIST4, EXAM4, MDM3 99244
Outpatient Consult N/E 80 ALL 3 HIST4, EXAM4, MDM4 99245
External Doctor — Service with Patient N/E   N/A first hour of prolonged services, with direct patient contact 99354
External Doctor — Service with Patient N/E   N/A each additional 30 minutes, with direct patient contact 99355
External Doctor — No Patient Contact N/E   N/A first hour of prolonged services, without direct patient contact 99358
External Doctor — No Patient Contact N/E   N/A each additional 30 minutes, without direct patient contact 99359
Doctor Standby N/E   N/A each 30 min after first 30 min, without direct patient contact 99360
Case Management Conference N/E 30 N/A by duration, approx 30 minutes 99361
Case Management Conference N/E 60 N/A by duration, approx 60 minutes 99362
Case Management Phone N/E   N/A simple or brief 99371
Case Management Phone N/E   N/A intermediate 99372
Case Management Phone N/E   N/A complex or lengthy 99373
Care Plan Coordination N/E 15 N/A 15 to 29 minutes, supervision of home health patient 99374
Care Plan Coordination N/E 30 N/A 30 minutes or more, supervision of home health patient 99375
Care Plan Coordination N/E   N/A 15 to 29 minutes, supervision of hospice patient 99377
Care Plan Coordination N/E   N/A 30 minutes or more, supervision of hospice patient 99378
Care Plan Coordination N/E   N/A 15 to 29 minutes, supervision of nursing facility patient 99379
Care Plan Coordination N/E   N/A 30 minutes or more, supervision of nursing facility patient 99380
Preventive Medicine — Evaluation/Management New   N/A initial care, age < 1 year 99381
Preventive Medicine — Evaluation/Management New   N/A initial care, age 1-4 years 99382
Preventive Medicine — Evaluation/Management New   N/A initial care, age 5-11 years 99383
Preventive Medicine — Evaluation/Management New   N/A initial care, age 12-17 years 99384
Preventive Medicine — Evaluation/Management New   N/A initial care, age 18-39 years 99385
Preventive Medicine — Evaluation/Management New   N/A initial care, age 40-64 years 99386
Preventive Medicine — Evaluation/Management New   N/A initial care, 65+ years 99387
Preventive Medicine — Evaluation/Management Est.   N/A period prev care, age < 1year 99391
Preventive Medicine — Evaluation/Management Est.   N/A period prev care, age 1-4 years 99392
Preventive Medicine — Evaluation/Management Est.   N/A period prev care, age 5-11 years 99393
Preventive Medicine — Evaluation/Management Est.   N/A period prev care, age 12-17 years 99394
Preventive Medicine — Evaluation/Management Est.   N/A period prev care, age 18-39 years 99395
Preventive Medicine — Evaluation/Management Est.   N/A period prev care, age 40-64 years 99396
Preventive Medicine — Evaluation/Management Est.   N/A period prev care, age 65+ years 99397
Preventive Medicine — Individual Counseling N/E 15 N/A individual counseling 99401
Preventive Medicine — Individual Counseling N/E 30 N/A individual counseling 99402
Preventive Medicine — Individual Counseling N/E 45 N/A individual counseling 99403
Preventive Medicine — Individual Counseling N/E 60 N/A individual counseling 99404
Preventive Medicine — Group Counseling N/E 30 N/A group counseling 99411
Preventive Medicine — Group Counseling N/E 60 N/A group counseling 99412
Preventive Medicine — Administrative / Assessment N/E   N/A admin/assess health risk 99420
Preventive Medicine — Other N/E   N/A unlisted preventive medicine service 99429
Newborn, Non-hospital N/E   N/A normal newborn care, non-hospital 99432
Newborn, Attend Delivery N/E   N/A attendance at delivery 99436
Newborn, Resuscitation N/E   N/A newborn resuscitation 99440
Life/Disability Evaluation Basic N/E   N/A basic life or disability exam 99450
Work/Med Disability — Doctor N/E   N/A work related exam by treating doc 99455
Work/Med Disability — Other N/E   N/A work related exam, non-treating doc 99456
Other Unlisted E&M N/E   N/A other services not listed 99499

 

 

Note: Completing the E&M coder section fields is not required to close an encounter.

 

To use the E&M coder section:

  1. Document the patient encounter as usual, completing all the fields needed before sign-off.
  2. Locate the E&M coder section on the Billing tab.
    • Providers: In the Sign-off stage of the encounter, click the Billing tab, then click E&M Coder.
    • Administrative staff: On the Claim: Billing tab in the Checkout stage, scroll down to the Services section to see confirmation of the E&M coder calculation.

The E&M coder section contains some fields to be completed by the user (Encounter Type and Medical Decision Making) and some fields that are system-populated (History and Physical Exam). Users can override the system-populated fields if necessary.

  1. Complete the fields under the Encounter Type and Medical Decision Making heading, and override the system-populated fields if necessary.

All E&M codes are calculated from some combination of the following clinical data points:

  • History of Present Illness
  • Past Family Social History
  • Review of Systems
  • Physical Exam
  • Medical Decision Making
  1. To calculate the justified CPT code with the greatest degree of accuracy, all fields must be populated; however, not all setting/service combinations will use all elements.
  2. Click the Calculate button.
    The E&M coder logic calculates all the data elements. If enough information exists to recommend an E&M code, the code appears in the lower left portion of the E&M coder section, under the Calculated CPT heading. You can use this E&M code as verification of the codes selected on the paper super-bill or billing slip.

Note: You cannot edit the resulting code directly. To adjust the CPT code recommended by the E&M coder, you can alter your Medical Decision Making selections, History selections, or Physical Exam selections in the E&M coder.

 

  1. Locate the encounter's Summary tab.
  2. Click the Calculated E&M Code link to display all the data points considered to determine the E&M code.
    Note: You cannot edit this information from this view.

 

Encounter Type
Type of Service

Select the appropriate type of service value from the menu. Most often the provider will select outpatient consult, outpatient visit, and/or preventive management services.
Note: The items available in the menu are filtered according to the Service Department of the appointment. The type of service corresponds to the Place of service type selected on the Departments page.

 

Settings Types of Service
All Prev Med — Admin / Assess
All Consult, confirmatory
All Ext Dr. svc w/ Patient
All Prev Med Eval / Mgt
All Case Mgt Conf
All Prev Med — Group Couns
All Ext Dr. — No Pat contact
All Prev Med — Indiv Couns
All Life / Disab Eval Basic
All Work / Med Disab — Dr.
All Neonatal IC
All Prev Med — Other
All Care Plan Coord
All Critical care
All Dr. standby
All Case Mgt Phone
All Other Unlisted E&M
All Work / Med Disab — Other
All Newborn H&P
All Newborn, non-hospital
All Newborn, sub hosp care
All Newborn, H&P w/ dischg
All Newborn. attend deliv
All Newborn resuscitation
Outpatient Outpatient Consult
Outpatient Outpatient Visit
Emergency Department Directed care
Emergency Department Physician care
Hospital Observation Observation discharge
Hospital Observation Initial observation
Hospital Inpatient Consult, initial inpatient
Hospital Inpatient Final discharge
Hospital Inpatient Consult, follow-up inpatient
Hospital Inpatient Initial hospital care
Hospital Inpatient Inpatient observ same day
Hospital Inpatient Subsequent hospital care
Long-term Facility Long term facility visit
Patient's Home Home visit
Nursing Facility Nursing assessment
Nursing Facility Nursing discharge
Nursing Facility Consult, initial patient
Nursing Facility Consult, follow-up inpatient
Nursing Facility Other services
Nursing Facility Nursing subsequent care
Type of Exam

Select the type of examination and guideline year for the code to be calculated. All physical exam findings will be correlated with MEDCIN findings, which are all correlated to a body area or organ system. Free-text data does not contribute to a physical exam system bullet.

Note 1: Your type of exam selection should be based on your practice's business policy for E&M coding. If you do not know the Guidelines identified by your practice for coding purposes, please contact your Practice Administrator.

Note 2: Only CMS guidelines for 1997 exams and the 1995 general multi-system exam types are provided because these exam templates are the only ones considered defensible in an audit. To view the CMS 1997 guidelines, see:
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/97docguidelines.pdf

 
Patient Status

Review the patient status that the E&M coder section selects for your patient. athenaClinicals assumes the patient is "New" if it is unable to find clinical and/or billing records for the patient in your practice in the last three (3) years.

Note: If you recently converted to athenaOne, your practice's clinical and/or billing records may not contain the patient's most recent visit information.
Bill By Time? Select this option if you want to bill by the amount of time spent with the patient.
Total Time

Time in minutes that the provider spent counseling the patient.

 

According to the AMA's updated CPT E/M guidelines, you can include the following time spent by the physician and other qualified health care professionals on the day of the encounter:

  • Face-to-face time with the patient
  • Preparing to see the patient (for example, reviewing tests)
  • Obtaining and reviewing separately obtained history
  • Performing a medically appropriate examination or evaluation
  • Counseling and educating the patient, family, or caregiver
  • Ordering medications, tests, or procedures
  • Referring and communicating with other health care professionals (when not separately reported)
  • Documenting clinical information in the electronic or other health record
  • Independently interpreting results (not separately reported) and communicating results to the patient, family, or caregiver
  • Care coordination (not separately reported)
History
Overall

The chart below from the CMS 1997 Guidelines for E&M Services shows the progression of the elements required for each type of history. To qualify for a given type of history, all three elements in the table must be met. (A chief complaint is indicated at all levels.)

 

History of Present Illness (HPI) Review of Systems (ROS) Past, Family, and/or Social History (PFSH) Type of History (aka Overall History)
Brief N/A N/A Problem Focused
Brief Problem Pertinent N/A Focused Expanded Problem
Extended Extended   Detailed
Extended Complete Complete Comprehensive

 

The Guidelines specify exactly how the three components combine to determine an overall level of history. Using the Medicomp determined levels as discussed in HPI, ROS, and PFSH, we find:

  • If the HPI level is greater than 0, the overall history is level 1 (Problem Focused).
  • If the HPI level is greater than 0 and the ROS level is greater than 0, the overall history is level 2 (Expanded Problem Focused).
  • If the HPI level is greater than 1, the ROS level is greater than 1, and the PSFH level is greater than 0, the overall history is level 3 (Detailed).
  • If the HPI level is greater than 1, the ROS level is greater than 2, and the PSFH level is greater than 1, the overall history is level 4 (Comprehensive).
HPI

History of present illness review

  1. Brief = If the total number of attributes that have some data in a structured, semistructured, or templated HPI is between 1 and 3, a "Brief" HPI is calculated.
  2. Extended = If the total number of attributes that have some data in a structured, semistructured, or templated HPI is >3, an "Extended" HPI is calculated.
PFSH

Stands for "past medical, family, and social history" review

 

Past, family, and social history do not rely on MEDCIN-backed terms. Past medical and social history questions are predefined by the practice, and family history is an ongoing list of conditions per family member. Editing a section has the effect of marking the section as reviewed; however, for the purpose of the E&M coder, the discussed checkbox also must be checked. Each section marked discussed in an encounter contributes a count to that section. NB: There are only two levels of service for the PFSH component. Further, the type of service and the setting have a bearing on the determined level as well as the individual counts.

  1. Pertinent = 1+ history sections were reviewed.
  2. Complete: 2-3 history sections were reviewed. Requirements depend on place of service and type of exam.
ROS

Review of systems

 

Counts the number of systems reviewed and not the actual review of the system. athenaClinicals derives the body system from each finding as selected in the ROS or well child ROS. The option to "denote ROS as noted in the HPI" will have the same effect of translating the HPI attribute "associated signs/symptoms" to system findings. These translated findings count towards the system in the ROS as follows:

  1. Problem pertinent = 1 system reviewed.
  2. Extended = 2-9 systems reviewed.
  3. Complete = 10-11 systems reviewed.

Types of ROS systems

  • Constitutional Symptoms
  • Eyes
  • Ears, Nose, Mouth, and Throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Integumentary (skin and/or breast)
  • Neurological
  • Psychiatric
  • Endocrine
  • Hematologic/Lymphatic
  • Allergic/Immunologic
Medical Decision Making
Overall

According to CMS: Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

  1. The number of possible diagnoses and/or the number of management options that must be considered.
  2. The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed.
  3. The risk of significant complications, morbidity, and/or mortality, as well as co-morbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

The chart below shows the progression of the elements required for each level of medical decision-making. To qualify for a given type of decision-making, two of the three elements in the table must be either met or exceeded.

 

Number of diagnoses or management options Amount and/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality Type of decision-making
Minimal Minimal or None Minimal Straightforward
Limited Limited Low Low Complexity
Multiple Moderate Moderate Moderate Complexity
Extensive Extensive High High Complexity
Dx/Management Options

Refers to the complexity of establishing a diagnosis and/or selecting a management option. Select the value from the menu that best describes the diagnosis management options:

  1. Minimal
  2. Limited
  3. Multiple
  4. Extensive
Complexity of Orders/Results

Amount and/or complexity of data to be reviewed (Complexity of Data). Select the value from the menu that best describes the complexity of orders or results to be reviewed:

  1. Minimal
  2. Limited
  3. Multiple
  4. Extensive
Problem Risk

The risk of complications and/or morbidity or mortality. This is a composite of the following factors:

  1. Risk of presenting problem (Problem Risk)
  2. Risk of diagnostic procedures ordered (Tests Risk)
  3. Risk of Management options selected (Mgt Risk)

Select from the menu the value that best describes the problem risk:

  1. Minimal
  2. Low
  3. Moderate
  4. High
Physical Exam
Exam Scope

Extent of physical exam

 

athenaClinicals users specify the type of examination and guideline year for the code to be calculated (see the "Type of Exam" section, above). All physical exam template findings are correlated with MEDCIN findings, which are all correlated to a body area or organ system. Free-text data does not contribute to a physical exam system bullet.

 

By analyzing the atomic units that have encounter data elements, along with the requirements specified in the Guidelines, a determination can be made of whether or not a particular bullet has been met. The conditions for satisfying each bullet are provided in the 1997 Guidelines and are not reproduced in this document. However, due to the complexity of correlating bullets met to a given level of service, this document reproduces excerpts from the Guidelines that summarize the requirements for each level. It is these requirements that are codified into the E&M calculator.

 

To qualify for a given level of multi-system examination, the following content and documentation requirements should be met:

  1. Problem Focused Examination — Should include performance and documentation of one to five elements identified by a bullet (•) in one or more organ system(s) or body area(s).
  2. Expanded Problem Focused Examination — Should include performance and documentation of at least six elements identified by a bullet (•) in one or more organ system(s) or body area(s).
  3. Detailed Examination — Should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet (•) is expected. Alternatively, a detailed examination may include performance and documentation of at least 12 elements identified by a bullet (•) in two or more organ systems or body areas.
  4. Comprehensive Examination — Should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.

To qualify for a given level of multi-system examination, the following content and documentation requirements should be met:

  1. Problem Focused Examination — Should include performance and documentation of one to five elements identified by a bullet (•) in one or more organ system(s) or body area(s).
  2. Expanded Problem Focused Examination — Should include performance and documentation of at least six elements identified by a bullet (•) in one or more organ system(s) or body area(s).
  3. Detailed Examination — Examinations other than the eye and psychiatric examinations should include performance and documentation of at least 12 elements identified by a bullet (•), whether in box with a shaded or unshaded border.
  4. Eye and psychiatric examinations should include the performance and documentation of at least nine elements identified by a bullet (•), whether in a box with a shaded or unshaded border.
  5. Comprehensive Examination — Should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected.
Calculated CPT
 

The calculated CPT code appears here.
Notes

Enter any notes about this E&M code.