The E/M interactive score sheet is designed to assist only with identifying the appropriate level of service defined by the work documented as rendered using the CMS documentation guidelines for E/M services.
The interactive score sheet must be used in conjunction with the patient’s medical record, the CPT manual, the CMS E/M guidelines for 1995, 1997, and/or AMA CPT E/M Code Guideline Changes for 2021 (effective for Office and other outpatient visits for dates of service on and after January 1, 2021) and/or the E/M Code and Guideline Changes for 2023 (effective for other E/M visits for dates of service on and after January 1, 2023). Other factors must be considered before arriving at the final code reported to Medicare (i.e., medical necessity and removing from the scoring any documented services reflective of separately reported preventive services and non-relevant documentation).
The E/M score sheet is designed to function based on the date of service for E/M visits. The date of service entered before making additional selections will be a determinant of options available for identifying a corresponding level of service. If the date of service is on or after 1/1/2023, the score sheet options are based on the AMA guidance to determine the level of E/M service performed. If the date of service is prior to 1/1/2023, the score sheet options are based on the 1995, 1997 E/M guidelines for E/M visits other than office and outpatient visits.
Before accessing the interactive score sheet, answer the question, “Does the documentation for service(s) billed include the date and legible signature of the rendering provider?”
If the response is yes, move to step 2.
If the response is No, the message below will appear.
Please review CMS signature guidelines, CMS IOM Pub. 100-08, Chapter 3 section 22.214.171.124 .
Click 'Accept' to acknowledge the terms of the user agreement to proceed.
Information icons indicate additional information is available. Click on the icon to display the information. Helpful resources icon displays several resources which can easily be accessed.
Time – Select the entry method for time. Session start/end calculation vs total time. Information icon displays additional information: “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."
Select "Session start/end calculation" to enter specific clock time increments.
Enter start and stop time, multiple entries may be entered.
Time may be deleted and reentered if corrections are needed. Total time and suggested E/M code will be displayed.
If "Total time entry" is selected, enter the total minutes. Suggested E/M code will be displayed.
Medical decision making (MDM) – Select the level of each component of medical decision making.
Note: To assist with selections, a link to the AMA table for that specific section along with details for each level are available by clicking on the information icon .
The MDM section is comprised of three subsections.
Number and complexity of problems addressed
Identifies the number and complexity of problem(s) that are addressed during the 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 system is not necessarily a unique condition.
Amount and/or complexity of data to be reviewed and analyzed.
Includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter.
Includes information obtained from multiple sources or inter-professional communications that are not separately reported.
Includes interpretation of tests that are not separately reported.
Ordering a test in 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 3 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.
Risk of complications and/or morbidity or mortality of patient management.
The level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated and the related need to initiate or forego further testing, treatment, and/or hospitalization.
Includes possible management options selected and those consider, but not selected, after shared medical decision making with the patient and/or family.
Based on information entered, suggested E/M will be displayed.
You may clear the score sheet or print the score sheet.
Please review the E/M center for more information. (JH) (JL)
When entering the patient information and the service type, if the date of service is prior to 1/1/2023, the 1995, 1997 guideline selection will display.
Select the set of E/M guidelines you wish to use to document this specific patient visits.
History is comprised of three subsections, history of present illness (HPI), review of systems (ROS) and past medical, family, and/or social history (PFSH). Hover over the elements and definitions will be displayed.
HPI – a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.
Brief - at least one to three elements of the present illness must be documented in the medical record.
Extended - either four or more elements of the present illness or four or more associated comorbidities or the status of three or more associated chronic or inactive conditions must be documented in the medical record.
ROS – an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced.
N/A - no inquiries regarding the system directly related to the symptom(s) identified in the HPI or any other system are documented in the medical record.
Problem pertinent - inquiries regarding the system directly related to the symptom(s) identified in the HPI are documented in the medical record.
Extended - inquiries regarding the system directly related to the symptom(s) identified in the HPI and between two and nine additional systems are documented in the medical record.
Complete - inquiries regarding the system directly related to the symptom(s) identified in the HPI and all additional systems are documented in the medical record.
PFSH – a review of the patient’s past medical history (e.g., previous illnesses, injuries, operations), family history (e.g., potential hereditary conditions), and an age-appropriate review of patient’s social history (current and past activities).
Examination – 1995 examination level is determined on the body areas or organ systems. Information icon provides details concerning the 4X4 method.
Examination - 1997 examination level is determined on the type of examination (general multi system or single organ system). Details will appear once a selecting is made.
Medical decision making – comprised of three subsections, number of possible diagnoses or treatment options, amount and/or complexity of data reviewed, and risk of significant complications and/or morbidity or mortality. Informational icons provides details on each of the risk of significant complications, morbidity, and/or mortality items.
Click on the box next to the applicable documentation statements. Total time may be used to select the level of E/M service if all three-criterion listed are documented in the medical record.
Once all selections have been made, the E/M interactive score sheet will automatically calculate a suggested E/M code based upon your entries.
You may clear the score sheet or print the score sheet.