| Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs | |
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| | E/M Interactive Score Sheet | | |
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Evaluation and management (E/M) services refer to visits furnished by physicians and qualified, licensed, non-physician practitioners.
Billing Medicare for a patient visit requires the selection of the code that best represents the level of E/M service performed.
The purpose of this interactive worksheet is to assist providers with identifying the appropriate E/M code based upon either the:
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1995 or 1997 Documentation Guidelines for Evaluation and Management Services, or
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AMA CPT E/M Code Guideline Changes for 2021 (effective for office and outpatient visits for dates of service on and after January 1, 2021), or
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E/M Code and Guideline Changes for 2023 (effective for other E/M visits for dates of service on and after January 1, 2023).
Since the 1995 and 1997 guidelines or AMA CPT E/M Code and guideline changes for 2021 and 2023 each specify different criteria to determine the level of E/M service performed, only one set of guidelines may be used to document a specific patient visit. For other E/M visit dates of service prior to January 1, 2023, this interactive worksheet offers providers the option to select either their preferred set of guidelines (1995 or 1997) or to select both sets for the purpose of comparison.
To emphasize the importance of medical necessity when reporting E/M services consider the following: all E/M services reported to Medicare
must be adequately documented so the medical necessity is clearly evident because federal law requires that Medicare not pay for services
for which the documentation does not establish such. For E/M services medical necessity of a visit as well as the CPT “level” of the service
must both be documented. Per the CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, Section 30.6.1 A  of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level
of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.
Documentation should support the level of service reported."
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| E/M Interactive Score Sheet |
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Use of this tool is at the discretion of the provider and is not intended to grant rights or impose obligations. This tool requires interpretation of provider documentation. Because interpretations may differ, use of this tool does not guarantee a specific audit result. It is the responsibility of the provider of services to ensure the correct submission of claims and responses to any remittance advice.
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When using this worksheet, the date of service entered before making additional selections will be a determinant of options available for identifying a corresponding level of service. To begin, please complete the following:
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Since the 1995 and 1997 guidelines each specify different criteria to determine the level of E/M
service performed, only one set of guidelines may be used to document a specific patient visit.
This interactive worksheet offers providers the option to select either their preferred set of
guidelines (1995 or 1997) or to select both for the purpose of comparison. To learn more about
the interactive features of this E/M resource, please refer to the
E/M interactive worksheet: Help guide and
E/M interactive worksheet FAQs
Note:This interactive worksheet was created as a tool to assist providers and is not intended as a replacement for the 1995 or 1997 E/M Documentation Guidelines
published by the Centers for Medicare & Medicaid Services (CMS).
Guidelines Selection (Please select the set of E/M guidelines you wish to use to document this specific patient visit.) | | Determining Level of E/M Services | |
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To determine the appropriate level of service for a patient's visit, it is necessary to first determine the applicable subcategory for the visit. Please select one of the following: |  |  |
| Office or Other Outpatient Services |
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| Hospital Inpatient, Observation, or Emergency Department Services |
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 | Note: Two or more encounters on the same date which includes an initial admission and discharge |
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| Nursing Facility Services |
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| Domiciliary, Rest Home or Custodial Care Services |
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 The extent of history of present illness (HPI), review if systems (ROS), and past medical, family, and/or social history (PFSH) obtained and documented is dependent upon clinical judgement and the nature of the patient's presenting problem(s). Note: For patient visits requiring an "interval history" (e.g., subsequent hospital, nursing care) a ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded; however, the review of the information should be documented by indicating its status (i.e., description of change(s)/no change to information). | | HPI (history of present illness) | |
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HPI Level (95): N/A | | | | PFSH (past medical, family, social history): | |
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| History level: None |
| | Examination: 1995 E/M Documentation Guidelines | |
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An examination may involve a single organ system or several. The extent of the examination performed is dependent upon the examiner’s clinical judgment, the patient’s history, and the nature of the presenting problem. Types of examination range from limited examinations of a single body area to general multi-system or complete single organ system examinations.  | | |
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0 Total Body Areas | | Exam Level (95): None |
| | Examination: 1997 E/M Documentation Guidelines | |
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A single organ system examination or a general multi-system examination may be performed by any physician regardless of specialty; however, the documentation requirements differ between the two examination types. The depth and type of the examination performed is dependent upon the examiner's clinical judgment, the patient's history, and the nature of the presenting problem. Use your cursor to hover over each choice for an explanation of what should be considered prior to making a selection. For further details regarding single organ system examinations, including bullet and shaded/unshaded border specifications, as well as individual examination elements of the applicable body area or system, consult the 1997 E/M Documentation Guidelines. |
System/Body Area | Exam Level(97): None |
Medical decision making refers to the level of complexity associated with establishing a diagnosis and/or selecting a management option. The level of complexity is measured by the following factors: - The number of possible diagnoses and/or the number of management options that must be considered by the examiner
- The amount and complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed by the examiner
- The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s) ordered, and/or the possible management options selected by the examiner
 | Number of Diagnoses or Treatment options |
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The number of possible diagnoses and/or the number of management options that must be considered is based upon the number and types of problems addressed during the patient visit, the complexity associated with establishing a diagnosis, and the management decisions that are made by the physician. | | |
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Element Level: None | | Amount and/or Complexity of Data Reviewed |
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The number of possible diagnoses and/or the number of management options that must be considered is based upon the number and types of problems addressed during the encounter, the complexity associated with establishing a diagnosis, and the management decisions that are made by the physician.
Element Level: None |
 | Risk of Significant Complications, Morbidity, and/or Mortality |
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 Level of Decision Making: None  If the physician documents total time and suggests that counseling or cordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider. Time: Face-to-face in outpatient setting Unit/floor in inpatient setting
Use the presenting illness as a guiding factor and clinical judgment about the patient's
condition to determine the extent of service to be performed. The key components of this
determination are the medical decision making or total time E/M services are performed.  | | Components for E/M code determination | |
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Instructions: Please select the entry method for time. | | | |
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Start Time | End Time | Session Minutes | Action |
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Total time | Suggested E/M code | No minute(s) | |
This service may qualify for additional prolonged services; refer to our E/M coding and guidelines article for additional information.
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Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Medical decision making is defined by three elements.
To qualify for a particular level of medical decision making, two of the three elements for a level of medical decision making must be met
or exceeded.
Instructions: Select each level of medical decision making which corresponds to the amount and/or complexity of problems/data. For details of each level, click on the informational icon.  | The number and complexity of problem(s) that are addressed during the encounter |
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This section allows you to identify the service level which corresponds to the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. | |
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 | The amount and/or complexity of data to be reviewed and analyzed |
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This data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not separately reported. It includes interpretation of tests that are not separately reported. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter. Data is divided into three categories: - Tests, documents, orders, or independent historian(s). (Each unique test, order or document is counted to meet a threshold number)
- Independent interpretation of tests.
- Discussion of management or test interpretation with external physician or other qualified healthcare professional or appropriate source
 This section allows you to identify the service level which corresponds to the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. | |
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 | Risk of complications and/or morbidity or mortality of patient management |
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The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment (s). This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family. | |
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 Medical decision making | E/M code | None | |
 Guidelines | History | Exam | Medical Decision Making | E/M Code |
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'95 Guidelines | None | None | None | Minimum code not met, please select another code | '97 Guidelines | None | None | None | Minimum code not met, please select another code |
To determine the appropriate level of service for a patient's visit, it is necessary to first determine whether the patient is new or already established. Please select one of the following: |  |  |
| | Components for E/M code determination | |
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Instructions: Please select the entry method for time. | | | |
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Start Time | End Time | Session Minutes | Action |
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Total time | Suggested E/M code | No minute(s) | |
This service may qualify for additional prolonged services; refer to our E/M coding and guidelines article for additional information.
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This service may qualify for additional prolonged services; refer to our E/M coding and guidelines article for additional information.
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Use the presenting illness as a guiding factor and clinical judgment about the patient's
condition to determine the extent of service to be performed. The key components of this
determination are the medical decision making or total time E/M services are performed. 
Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Medical decision making is defined by three elements.
To qualify for a particular level of medical decision making, two of the three elements for a level of medical decision making must be met
or exceeded.
Instructions: Select each level of medical decision making which corresponds to the amount and/or complexity of problems/data. For details of each level, click on the informational icon.  | The number and complexity of problem(s) that are addressed during the encounter |
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This section allows you to identify the service level which corresponds to the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. | |
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 | The amount and/or complexity of data to be reviewed and analyzed |
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This data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not separately reported. It includes interpretation of tests that are not separately reported. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter. Data is divided into three categories: - Tests, documents, orders, or independent historian(s). (Each unique test, order or document is counted to meet a threshold number)
- Independent interpretation of tests.
- Discussion of management or test interpretation with external physician or other qualified healthcare professional or appropriate source
 This section allows you to identify the service level which corresponds to the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. | |
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 | Risk of complications and/or morbidity or mortality of patient management |
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The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment (s). This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family. | |
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 Medical decision making | E/M code | None | |
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Time may be documented or recorded as multiple entries that will be aggregated for that date of service or in a free-form manner combining all with a single entry. | | | | |
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