Medicare Part B 101 Manual

Medicare Part B 101 Manual

Evaluation and Management Services

Table of Contents

[Return to Top]

Evaluation and Management Services

E/M services are professional face to face services rendered by a physician or NPP in various sites or POS. The nature and amount of physician work and documentation will vary by type of service, place of service and the patient’s status. Reimbursement for E/M services is dependent upon the supporting documentation in the medical record and the presenting problem or reason for the encounter.

[Return to Top]

General Principles of Medical Record Documentation

  • The medical record should be complete and legible
  • The documentation of each patient encounter should include:
    • The reason for the encounter and relevant history, physical examination findings and prior diagnostic test results
    • Assessment, clinical impression or diagnosis
    • A plan of care and
    • the date and legible signature with credentials of the performing provider
  • The supervising provider, if applicable, should cosign the note
  • If abbreviations are used that are not standard medical abbreviations, a key should be included
  • The reason for the service should be clear and consistent with the diagnoses submitted
    • ICD-10-CM for services performed on or after 10/1/2015
  • If the service is a time based service, such as critical care (CPT 99291–99292), the time must be included in the documentation

[Return to Top]

New Patient and Established Patient

E/M services are categorized by place of service, type of service and level of service. Some categories also differentiate between a new patient and an established patient.

  • New patient: one that has not been seen by the provider or a provider of the same specialty in the same group for the previous three years
  • Established patient: one that has been seen by the provider or a provider of the same specialty in the same group for the previous three years

The descriptors for the levels of E/M services are determined based on the level of MDM or total time spent in the care of the patient. All E/M services must include a medically necessary and relevant history and exam portion. The level of MDM or time spent determines the code selection.

The CPT manual details the requirements for each E/M procedure code. Keep in mind that the level of service must also be medically necessary. The medical necessity is based on the patients presenting problem and the necessary level of intervention required.

For visits that may be more time intensive than the MDM would seem to indicate, time can be used to determine which CPT code to use.  Each service may be individually determined whether to use MDM or time as the determining factor.

Please note that with the CPT E/M guidelines adopted for use in 2021 for Office/Other Outpatient services and then in 2023 for the other E/M categories, the 95 and 97 E/M Guidelines, nor any other previous E/M guidelines, apply to code selection after those dates of service. This also means previous documentation training tools are no longer valid. The MDM table printed in the CPT book each year will dictate the levels of MDM.

[Return to Top]

What Should Be Provided if Medical Records Are Requested for Review?

The following should be considered if applicable to the service being reviewed. This is not intended to be an all-inclusive list.

  • Progress/visit notes
  • Physician orders
  • Medication records
  • Diagnostic test results (radiological studies, laboratory reports)
  • History and physical
  • Treatment plan if applicable
  • Procedure reports

The information could also include previous dates of service that support the need for the date of service being requested.

[Return to Top]

Related Content

For more details regarding E/M services, please refer to the following resources:

Revised 9/27/2023