Section 3: Evaluation and Management
Note: Please see the ADDENDUM at the end of this document.
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Classification of Evaluation and Management (E/M) Services
The E/M section is divided into broad categories such as office visits, hospital visits, and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital visits (initial and subsequent). The subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes. This classification is important because the nature of physician work varies by type of service, place of service, and the patient’s status.
The basic format of the levels of E/M services is the same for most categories. First, a unique code number is listed. Second, the place and/or type of service is specified, e.g., office consultation. Third, the content of the service is defined, e.g., comprehensive history and comprehensive examination. (See levels of E/M services following for details on the content of E/M services.) Fourth, the nature of the presenting problem(s) usually associated with a given level is described. Fifth, the time typically required to provide the service is specified. (A detailed discussion of time is included in this section.)
Definitions of Commonly Used Terms
Certain key words and phrases are used throughout the E/M section.The following definitions are intended to reduce the potential for differing interpretations and to increase the consistency of reporting by physicians in differing specialties.
New Patient |
A new patient is one who is new to the physician or an established patient with a new industrial injury or condition. Only one new patient visit is reimbursable to a single physician or medical group per specialty for evaluation of the same patient relating to the same incident, injury, or illness. |
Established Patient |
An established patient is a patient who has been seen
previously for the same industrial injury or illness by the physician. |
Referral |
A referral is the transfer of the total or specific care of a patient from one physician to another and does not constitute a consultation. (Initial evaluation and subsequent services are designated as listed in E/M services.) |
Concurrent Care |
The provision of similar services, e.g., hospital visits to the same patient by more than one physician on the same day. When concurrent care is provided, no special reporting is required. |
Counseling |
A discussion with a patient and/or family concerning one or more of the following areas:
|
Unlisted Service
An E/M service may be provided that is not listed in this section of CPT.
When reporting such a service, the appropriate “Unlisted” code may be used to indicate the service,
identify it “By Report” as discussed in Item 4. The Unlisted Services and accompanying codes for the
E/M section are as follows:
99429 Unlisted preventive medicine service
99499 Unlisted evaluation and management service
By Report
An unlisted service or one that is unusual, variable, or new may require a special report demonstrating the medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service. Additional items which may be included are complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and the follow-up care.
Modifiers
Listed services may be modified under certain circumstances. When
applicable, the modifying circumstance against general guidelines should be identified by the addition
of the appropriate modifier code, which is reported by a two-digit number placed after the usual
procedure number from which it is separated by a hyphen.
Non-CPT procedure codes and modifiers have been included in this schedule to reflect the services
of Health Care providers not addressed in CPT. These codes have been identified as “state specific
codes” within the description of the service.
In some circumstances, CPT modifiers have been revised. In this fee schedule only two digit modifiers
are to be used.
PLEASE REFER TO THE AMERICAN MEDICAL ASSOCIATION’S CPT MANUAL FOR MORE INFORMATION ON PROPER CODING FOR EVALUATION AND MANAGEMENT SERVICES.