Evaluation and management is the most important part of the practice for an internist and coding for these visits can have an important effect for the bottom line of a practice. The decision about what level to bill an evaluation and management code is rarely clear to most physicians. In order to determine what code to select for an evaluation and management procedure, it helps to first learn the elements of a code. Once you understand the elements and how they come together to create the level, it can be a lot easier to select a code with confidence. In this article, we will focus on the documentation standards for evaluation and management codes 

E/M Coding Basics for Internal Medicine

Cheif Complaint

Every evaluation and management visit should start with a chief complaint - some kind of reason why the patient needs to be seen. Only a simple explanation is needed, it may be “cough” or “1 year recheck of diabetes” or “nausea since Tuesday.” The chief complaint is required in order to establish medical necessity, a fundamental element of the Medicare program and a required element for billing this series of codes for the private sector as well. 
It is best to avoid overly generic chief complaints like “annual check-ups” or “feeling sick.” Chief complaints such as “no complaints” or “no symptoms” are even worse and could cause serious problems if the claim is audited. Before you even think about selecting a code, you have to document a chief complaint, or the visit will not be considered properly coded.
Once you have the chief complaint, you can move on to the three elements that vary with each that you use to consider when selecting a coding level: history (everything the patient tells you); examination (everything you discover on examination); and medical decision making (how sick the patient is and what you do about it). 


History is all subjective information that is gathered from the patient. The information may be gathered in the form of an interview or a questionnaire that the patient completes. 
There are three different elements of the history to be considered for a coding level: 1) History of Present Illness; 2) Review of Systems, and 3) Past, Family, and Social History. 
  • History of Present Illness: There are a number of defined elements in history that will help you in selecting a level. It is important to note that the physician should only ask the information that is pertinent to the patient, and should not be asking unnecessary information in order to reach a higher coding level. When an auditor looks at an evaluation and management visit, he will look for elements like: location, duration, timing, severity, and context. 
  • Review of Systems: The review of systems is considered part of the history in which the physician asks the patient about his health by each body area or organ system. The review of systems is often left out of the visit or the documentation and is a primary driver for codes that do not meet high standards for history. There are 14 different body areas and organ systems that are considered for the review of systems. Many physicians are best able to capture the review of systems using a form completed by the patient at each visit, allowing the patient to complete the documentation for the physician.
  • Past, Family, and Social History: In addition to asking the patient about his current state of health, a physician may find it appropriate to ask the patient about her past history of illness, social history, or her family’s history of illness. These elements are also considered a part of history. In order to reach the highest level of code on a new patient, a physician must ask about past medical, family, and social history. Many physician practices request that patients complete forms generally describing their state of health at the time of the visit. 


It is important to note that the extent of the exam should be driven by the patient’s presenting problem. A patient with a relatively simple problem in most cases will not require a comprehensive exam. Doing such an exam merely to raise the coding level is not appropriate and may be considered fraudulent. Similarly, writing only simple documentation when more complex documentation is called for is not good service to the patient.

Medical Decision Making

The medical decision-making element of a code is the most complex and the most open to debate. The history and examination sections include counting elements that make determining a level relatively simple - the medical decision-making element includes judgments about what is considered serious or major or an intervention. 

There are three elements that go into the scoring of the medical decision-making section:
  • The first consideration is the number and severity of diagnoses or treatment options. There is a fairly complicated rubric that is used, but as a more basic consideration, the more difficult it is to make a decision about what to do with the patient, the higher the score is. 
  • The second consideration in determining the score for the medical decision-making section is the amount and  complexity of the data reviewed. This would include all data that is not a part of the history or the examination and may include lab studies, x-rays, reviewing old records, or speaking with the patient’s previous physician. It is important to note in this section that an auditor will consider a note ordering a study to be the same as reviewing the study, so the data need not be reviewed before the patient is dismissed. Again, there is a fairly complex rubric for determining the precise score but again, the more data that is reviewed by the physician, the higher the score in this section. 
  • The third consideration in medical decision-making scoring is the risk of complications and/or morbidity or mortality. This element itself is composed of three separate considerations: 1) nature of presenting problem, 2) diagnostic procedures ordered, and 3) management options selected. Each of these elements is determined to be minimal, low, moderate, or high risk. 
Understanding the basics of evaluation and management codes can significantly improve revenue for your internal medicine practice. Staying up-to-date with new changes is one of the most important ways to avoid errors. You can consider outsourcing your billing and coding needs. 

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Published By - Medical Billers and Coders
Published Date - Feb-22-2021 Back

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