ED Coding and Reimbursement Alert

Question: Evaluation and management (E/M) has three components: history, exam and decision-making. Do all three of these components have to be the same levels?

Thomas Foreman, MD
Hornell, N.Y.

Answer: The lowest component decides which code should be used. For example, if the history is problem focused, the examination is detailed and the level of decision-making is moderate, then the proper code is 99201 (office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: a problem-focused history, a problem- focused exam and straightforward medical decision making) due to the history component. For an established patient, two components must be met to determine a level of service. For example, if the history is problem focused, the examination is expanded and the level of decision-making is moderate, the code would be 99213 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history, an expanded problem-focused exam and medical decision making of low complexity.)

For more information on E/M coding, see the August 2000 ED Coding Alert Medical Decision-Making Is Key Factor in Determining Level of E/M Reimbursement page 57.