Evaluation and Management (E&M) Service – E&M services are performed by physicians and non- physician practitioners (NPPs).  The level of E&M is selected using the patient type (new or established patient), the setting of service and the level of E&M performed.  E&M services include office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services.

New patient codes  – (99201, 99202, 99203, 99204, and 99205)  in the office or outpatient setting indicate that the patient has not received any professional services within the last three (3) years from the physician/NPP or a physician/NPP of the same specialty who belongs to the same practice group.

Established patient codes –  (99211, 99212, 99213, 99214, 99215) in the office or outpatient setting indicates that the patient has received professional services within the last three years from the physician/NPP or another physician/NPP from the same specialty who belongs to the same practice.

NPP – Physician Assistants and Nurse Practitioners are commonly referred to as Non Physician Practitioners (NPP)

3 Key Components – History, Exam and Medical Decision Making are referred to as the 3 key components when determining the level of Evaluation & Management Services.

STANDARD

New Patient E&M Service

All three (3) “key” components, history, examination and medical decision-making, must be included in the medical record documentation.  Below is a table showing the elements required for each of the different levels of service.

Code	History	Examination	Decision Making
99201	Problem focused	Problem focused	Straightforward
99202	Expanded problem focused	Expanded problem focused	Straightforward
99203	Detailed	Detailed	Low complexity
99204	Comprehensive	Comprehensive	Moderate complexity
99205	Comprehensive	Comprehensive	High complexity

Established Patient E&M Service

Two of the three key components, history, exam, medical decision making, must be indicated in the medical record.  Below is a table showing the elements required for each of the different levels of service.

Code	History	Examination	Decision Making
99212	Problem focused	Problem focused	Straightforward
99213	Expanded problem focused	Expanded problem focused	Low complexity
99214	Detailed	Detailed	Moderate complexity
99215	Comprehensive	Comprehensive	High complexity

Minimal Services Code (99211) does not require the actual presence of the physician with the patient. However, the physician must be physically present in the office suite during the visit in order to bill for services provided by ancillary staff under the physician’s supervision. Documentation of minimal evaluation is required.  Refer to Standard B-408 for additional information on Non Physician Practitioner (NPP) guidelines.

 REGULATORY REFERENCES

Evaluation and Management Services Guide. Medicare Learning Network. December 2010.  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

CMS Claims Processing Manual 100-04, Ch. 12, 30.6 Evaluation and Management Codes-General. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Centers for Medicare and Medicaid (CMS)

 QUESTIONS

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Report & Response at (213) 740-2500 or (800) 348-7454.