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Documentation Guidelines for CPT Evaluation and Management Services                         

Introduction

The Current Procedural Terminology (CPT) manual, published annually by the American Medical Association (AMA) has definitive documentation guidelines that are required for each level of service code within the various E&M categories.

The E&M categories for office/outpatient; office and in-patient consultations; and emergency room services each have five levels of coding.

The E&M categories of initial and subsequent hospital visits each have three levels of coding.

The seven components to the code selection are:

  • The extent of History
  • The extent of Exam
  • The extent of Medical Decision Making
  • New or established patient
  • Nature of the presenting problem
  • Counseling or coordination of care
  • Amount of time spent with the patient

The charts that follow address the three KEY components to consider when selecting the level of code:

  • History
  • Exam
  • Medical Decision Making

New patients and consultations require that the three key components be met or exceeded.

Established patients and subsequent visits require that two of the three key components be met or exceeded.

Code Selection

The information provided at the top of the chart for each category will inform you if three or two key components must be met or exceeded to select the code.

  1. Select the appropriate level of history, exam, and medical decision making.
  2. If a row has two or three circles, select the code associated with that row.
  3. If several rows have one circle each, find the row that contains the second circle, and select the code associated with that row.

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