I know you are probably familiar with the changes made to the Outpatient Office Visit Evaluation and Management Codes, but are you still using the old guidelines for consultations and other settings? These requirements are still in place until January 1, 2023. This video will provide a refresher for what is still required for the Evaluation and Management Services outside of 99201 through 99215. The 1995 and 1997 Evaluation and Management Guidelines require three key components, history, examination, and medical decision-making. Unlike the new guidelines that base the level of service solely on medical decision-making, 1995-97 guidelines still require specific elements of history and examination. E&M services have four possible levels of complexity, straightforward, expanded, detailed, and comprehensive. The levels of complexity then translate into levels of service. Guidelines require the levels of complexity to be met for all three components in order to build that level of service. For example, the consultation with a detailed history, comprehensive exam, and high medical decision-making would be billed as 99243 because it did not meet the highest level of service for all three components to bill a 99245. New patient visits, such as an initial inpatient visit, also require all three components meet the level of complexity for that service. It is important to note that both 99222 and 99223 require a comprehensive history and examination. For subsequent and established patient visits, two out of the three components must reach the level of complexity. Let's take a look at the required components in more detail. History is composed of history of present illness, review of systems, past medical history, social history, and family history. History of present illness has eight possible components, location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms. To reach a comprehensive HPI, four elements must be documented where the status must be given for three chronic illnesses. Review of systems is comprised of constitutional, eyes, ENT, cardiovascular, respiratory, gastrointestinal, genitourinary, intragumentary, musculoskeletal, psychiatric, endocrine, neurological, hematologic, and allergic. Note that 10 systems must be reviewed to reach comprehensive. Some payers allow a statement of all others reviewed and negative if at least one system is reviewed, but check with your payer. Past medical history includes past medical conditions, past surgeries, allergies, medications, and immunizations. Social history includes employment, education, living arrangements, marital status, and the use of drugs, alcohol, and tobacco. Family history includes diseases related to the chief complaint, health status of parents, siblings, and children, and hereditary diseases. One element from each past medical, family, and social history are required to reach comprehensive. When history is unobtainable, the guidelines allow for this, but the note must state why and give as much history as available from other sources. There are two different sets of guidelines for examination, 1995 and 1997. Either set may be used. 1997 is more specific than 1995. The 1995 guidelines are made up of organ systems and body areas. A comprehensive exam under the 1995 guidelines is comprised of an exam of eight or more organ systems. Body areas do not count when calculating the number of systems examined. 1997 examination guidelines break down each system into bullet points. Levels of service are determined based on the number of bullets documented. Only comprehensive requires the bullets to come from different systems. Medical decision-making has three components, nature of presenting problem, data to be reviewed, and risk. To reach the level of complexity, two out of the three components must meet the level. Nature of presenting problem is based on a point system. Points can be added for multiple problems addressed. Data to be reviewed is also calculated on a point system. Risk is calculated using the table of risk. Only one component need be met to reach the complexity level. In order to bill based on time, counseling or coordination of care must account for more than 50% of a visit. Information must include the total time spent, time spent in counseling or coordinating care, and a description of what was counseled and coordinated. Reminder, the 95-97 guidelines still apply for 2022 to all E&M services that are not office visits. This includes consultations and hospital visits. Be sure you are using the correct guidelines for the service you are billing.

Evaluation and Management services

E&M codes

1995 E&M guidelines

1997 E&M guidelines

level of complexity