No More Counting! Current Requirements for Performing and Documenting E/M Services
Authors: The Society for Maternal-Fetal Medicine (SMFM) Coding Committee; Barbra Fisher, MD, PhD, FACOG; Emily Hill, PA.
The CPT guidelines for selecting levels of Evaluation and Management (E/M) Services were revised in 2021 and 2023 for outpatient/office and inpatient/hospital, respectively. In the updated guidelines, levels of service for office- and hospital-based (E/M) codes are based on either the medical decision-making elements or the total time spent on the date of the encounter. In contrast to (now) outdated guidelines, the current code descriptors and CPT guidelines indicate only that a “medically appropriate history and/or examination” is required to choose a level of service.
Previously, levels of service were based in part on the extent of the history and the examination. For instance, in the past, one would need to include a specified number of reviews of systems and exam elements to meet a level of service. One of the goals for the revised E/M guidelines was to reduce the documentation burden for clinicians and avoid including clinically irrelevant information in the medical record. With the wide use of electronic medical records, it may be tempting to clone documentation and include prepopulated system review and physical examination in the record, neither of which are necessary to meet current coding compliance standards.
While counting elements is no longer necessary from a coding perspective, a medically appropriate history and/or examination is required. This requirement eliminates the need for documentation of a comprehensive examination and history for most high-level encounters (e.g.99204, 99205, 99244, 99245, 99254, 99255, 99223). In some instances, a focused examination may be warranted, while other times an examination may not be necessary at all for appropriate care of the patient. For instance, a patient seen for management of anticoagulation in the setting of her known thrombophilia might not need an examination performed, or documented, while a patient presenting with postpartum breast pain would warrant a breast examination. Likewise, in the past, specific history components (e.g. history of present illness; review of systems; and past medical, family, and social history) were necessary to choose a level of service. In the current guidelines, there is no requirement for all these elements to be documented for each encounter.
Documentation must support the medical necessity of the service and include relevant clinical information so that the medical decision-making elements can be adequately evaluated. This documentation might include the type of problem and its complexity and duration, the extent of data analyzed at the encounter, and the plans for further testing and treatment. Some of this information might be found in the subjective section of a typical SOAP note and/or under the assessment and plan section of the note.
Continuing to follow prior documentation guidelines regarding the history and examination components does not (necessarily) contribute to the selection of the E/M level of service and may distract from relevant clinical information necessary for the care of the patient.
Members should submit any coding questions to the SMFM Coding Committee Ask a Coding Question website (https://www.smfm.org/coding/questions/new). Additional information and resources are also available on our coding website. Thank you very much.