Determination of Level of E&M Code

The three key elements in selecting the appropriate complexity of the E&M code are history, examination, and medical decision-making.  These components must meet or exceed the minimum requirements specified in the E&M guidance of the CPT references.  When determining the level of history for an E&M code the documented elements in the History of Present Illness (HPI) may also be counted in the Review of Systems (ROS) and/or the Past Family Social History (PFSH) when appropriate.  It is not necessary to repeat a documented item of history in order to count in two or all three elements of the history component.  There are four contributory factors, which include nature of presenting illness, coordination of care, counseling and time.  More E&M documentation guideline information may be found on the CMS website at http://www.cms.hhs.gov/.

Encounter Duration
3.1.5.1. Time is not a dominant factor for assigning the appropriate E&M code in most scenarios.  The time frames identified in E&M code descriptions represent a general range of times that will vary depending on actual clinical circumstances.  The severity of illness as documented by history, examination, and medical decision-making should determine the choice of office visit or consultation E&M code.

Counseling and coordination exception.  Counseling and coordination is an exception to the statement that “time is not a dominant factor” in selecting the E&M code.  Time is a determining factor when counseling or coordination of care represents more than 50 percent of the time a provider spends face-to-face with the patient, the family, or both.  Documentation must be sufficient to indicate why the additional time was necessary and what occurred during that time.  There must be an indication of the amount of time, usually with a “time in” and “time out” documented as well as the amount of time spent counseling.

Other specific exceptions.  Specific exceptions when time is always a factor are prolonged services, critical care, discharge services, and patient transport.  Time plays a role in the extended duration of the encounter.  Extended time may be identified in two ways, modifier –21 (Prolonged E&M Services), or E&M codes 99354-99357 (Prolonged Services).  Modifier -21 is used to designate the total duration of provider-patient face-to-face time when it goes beyond the typical time of the encounter.  Modifier –21 can only be used with the highest level E&M code (e.g., 99215, 99245).  Codes 99354-99357 are used when treatment exceeds the E&M code by more than 30 minutes.  Codes 99354-99357 can be used as add-on codes with any level of E&M service.  Modifier –21 and codes 99354-99357 cannot be used with the same encounter.  As with increasing the level of an encounter due to counseling time, the documentation must support the need for additional time as well as an indication of the length of the encounter (e.g. time in/time out).