Use of Highest Levels of E/M Codes
To bill the highest levels of visit codes, the services furnished must meet the
definition of the code (e.g., to bill a Level 5 new patient visit, the history must
meet the CPT’s definition of a comprehensive history).
The comprehensive history must include a review of all the systems and a
complete past (medical and surgical) family and social history obtained at that
visit. In the case of an established patient, it is acceptable for a physician to
review the existing record and update it to reflect only changes in the patient’s
medical, family and social history from the last encounter, but the physician must
review the entire history for it to be considered a comprehensive history.
The comprehensive examination may be a complete single-system exam such
as cardiac, respiratory, psychiatric or a complete multi-system examination
