Outpatient Evaluation & Management code (E/M)

Introduction

A nationally recognized subset of CPT codes.

Components:

• key components
  • history
  • examination
  • medical decision making
• non-key components
  • counseling
  • coordination of care
  • nature of presenting problem
  • time spent
  • complexity Outpatient E/M codes do NOT include:
• surgical procedures
• laboratory tests
• imaging
• consultations from other providers
• critical care
• emergency services

A patient is new if he/she has not received professional services from you or another provider

• in the same specialty or subspecialty
• at medical center in question or its satellite
• within past 3 years Elements of history:
• chief complaint (CC) stated in patient's own words
• history of present illness
  • location, severity, timing, quality, context, duration, modifying factors, associated signs & symptoms
• review of systems