Introduction to Evaluation and Management
Chapter 1: Documentation and the Medical Record
What Is Documentation
Official Principles of Documentation
Baseline Data
Initial Examination
Advance Directives
Documenting Tests, Services and Procedures
Ancillary Tests
Services and Procedures
Documenting Telephone Calls
Tracking Time
Correspondence Between Healthcare Professionals
Altering the Medical Record
Keeping It Neat
What to Include
Fraud and Abuse
Malpractice
Documentation Formats
SOAP Notes
Preprinted Forms
Electronic Medical Record Templates
Scribed Services
Example of a Scribed Service
Signature Requirements
Handwritten Signatures
Electronic Signatures
Evaluate Your Medical Records
Medical Record Documentation Questionnaire
Chapter 2: Documenting and Selecting E&M Services for Office and Other Outpatient Visits
What has Changed?
Medical Decision Making (MDM): Selecting a Level of Service
Number/Complexity of Problem(s) Addressed During the Encounter
Amount/Complexity of Data to be Reviewed and Analyzed
Risk of Complications, Morbidity/Mortality of Patient Management
Decisions Made at the Visit
Medical Decision Making: Putting it All Together
Medical Decision Making Table
Time: Selecting a Level of Service
Prolonged Service Codes: 2021 Office and Other Outpatient Visits
Summary of 2021 E&M Office or Outpatient Services Guidelines
Summary of Guideline Differences
Chapter 3: Documenting and Selecting Other E&M Services
Step-by-Step Documentation
Components of E&M Services
The History
Chief Complaint
History of Present Illness
Review of Systems
Past, Family and Social History
The Examination
Content and Documentation Requirements
1995 Guidelines Versus 1997 Guidelines
1997 Examination Guidelines
Single Organ System Examinations
Ear, Nose and Throat Examination
Hematologic/Lymphatic/Immunologic Examination
Musculoskeletal Examination
Neurological Examination
Psychiatric Examination
Respiratory Examination
Skin Examination
The Complexity of Medical Decision-Making
Number of Diagnoses or Management Options
Amount and/or Complexity of Data to be Reviewed
Risk of Complications and/or Morbidity or Mortality
Counseling or Coordination of Care
Hospital Services
Chapter 4: Shared/Split Care and Incident-To
Documentation for Incident-To Services
Chapter 5: Modifiers for E&M
Examples of Proper Use of the 25 Modifier
Examples of Improper Use of the 25 Modifier
Key Points
Examples of Related Diagnoses
Examples of Unrelated Diagnoses
Chapter 6: Teaching Physician Guidelines for E&M
Introduction
Documentation Requirements
Primary Care Exception
Minor Procedures Performed in the Office Setting
Psychiatry
Time-Based Codes
Teaching Physician Modifiers
Chapter 7: Telehealth/Telemedicine Services
Online Digital Evaluation and Management Services
Qualified Nonphysician Health Care Professional Online Digital
Evaluation and Management Services
Interprofessional Telephone/Internet/Electronic Health Record Consultations
Digitally Stored Data Services/Remote Physiologic Monitoring
Remote Physiologic Monitoring Treatment Management Services
Communication Technology-Based Services
Telehealth Services and CMS
Telehealth Services During the Public Health Emergency (PHE)
Chapter 8: Preventive Services
Preventive Care
Preventive Medicine Services (99381–99397)
Modifier 33
Medicare Preventive Services
Initial Preventive Physical Exam (IPPE)
Important Reminders
Nine Components of IPPE
Annual Wellness Visit
Sample Health Risk Assessment
Breast And Pelvic Screenings (G0101)
Screening Hemoccults (G0328)
Preventive Counseling/Risk-Factor Reduction
Tobacco Use Cessation Counseling
Chapter 9: Pediatric Medical Records
Baseline Data
Medication and Problem Lists
Allergies and Adverse Reactions
Pediatric Preventive Screening
Immunizations
Immunization Administration for Vaccines/Toxoids
Health Education and Counseling
Chapter 10: Reviews and Appeals
Medical Reviews
What Encourages a Review?
Policy Development
The Many Faces of a Medical Review
Consequences of Claim Errors
False Claims Act
To Get a Passing Grade
Types of Appeals
Appendix 1: Categories of E&M Services
Office or Other Outpatient Services (99202–99205, 99211–99215)
Hospital Observation Services (99217–99226)
Hospital Inpatient Services (99221–99223, 99231–99233)
Observation or Inpatient Care Services (Including Admission and Discharge Services)
(99234–99236)
Hospital Discharge Services (99238–99239)
Consultations
Office or Other Outpatient Consultation, New or Established Patient (99241–99245)
Inpatient Consultation, New or Established Patient (99251–99255)
Emergency Department Services (99281–99285)
Emergency Department Services – Facility Component (99281–99285)
Critical Care Services (99291–99292)
Nursing Facility Services (99304–99318)
Initial Nursing Facility Care (99304–99306)
Subsequent Nursing Facility Care (99307–99310)
Nursing Facility Discharge Services (99315–99316)
Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services
(99324–99337)
Domiciliary, Rest Home (e.g., Assisted Living Facility), or Home care Plan
Oversight Services (99339–99340)
Home Services (99341–99350)
Prolonged Services With Direct Patient Contact (99354-99357)
Prolonged Service Without Direct Patient Contact (99358–99359)
Prolonged Clinical Staff Services with Physician or Other Qualified
Healthcare Professional Supervision
Prolonged Service With or Without Direct Patient Contact on the Date of
an Office or Other Outpatient Service (99417)
Office or Other Outpatient Services – New Patient (99205)
Office or Other Outpatient Services – Established Patient (99215)
Comparison of Prolonged Service Codes (99354, 99355, 99356,
99358, 99359, 99417)
Case Management Services
Home and Outpatient International Normalized Ratio (INR) Monitoring Services
Medical Team Conference
Care-Plan-Oversight Services (99374–99380)
Newborn Care Services
Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal
Critical Care Services
Initial and Continuing Intensive Care Services
Cognitive Assessment and Care Plan Services
Care Management Services
Chronic Care Management Services
Complex Chronic Care Management Services
Principle Care Management
Psychiatric Collaborative Care Management Services
Transitional Care Management Services
General Behavioral Health Integration Care Management
Appendix 2: Sample Documentation for E&M Codes
Sample Documentation for Code 99202
Sample Documentation for Code 99203
Sample Documentation for Code 99204
Sample Documentation for Code 99205
Sample Documentation for Code 99211
Sample Documentation for Code 99212
Sample Documentation for Code 99213
Sample Documentation for Code 99213
Sample Documentation for Code 99214
Sample Documentation for Code 99214
Sample Documentation for Code 99215
Sample Documentation for Code 99221
Sample Documentation for Code 99223
Sample Documentation for Code 99231
Sample Documentation for Code 99231
Sample Documentation for Code 99232
Sample Documentation for Code 99241
Sample Documentation for Code 99242
Sample Documentation for Code 99253
Sample Documentation for Code 99253
Sample Documentation for Code 99255
Sample Documentation for Code 99281
Sample Documentation for Code 99282
Sample Documentation for Code 99283
Sample Documentation for Code 99284
Sample Documentation for Code 99285
Sample Documentation for Code 99415
Sample Documentation for Code 99483
Sample Documentation for Code 99490
Sample Documentation for Code 99492
Sample Documentation for Code 99493
Appendix 3:
Sample Documentation Forms
Self-Audit Form
