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Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.



Introduction and Definitions (1995 and 1997 E/M Guidelines)

The purpose of this entire website is to provide physicians with the tools they need to educate themselves about E/M coding and documentation.  The fundamental principle of E/M University is that knowledge is power when it comes to E/M coding and documentation.  Too many physicians are chronically undercoding for their services because they don’t understand the rules.  A working knowledge of the E/M coding is the best way to ensure optimal compliance and avoid inadvertent undercoding.   Physicians who understand the idiosyncratic process of E/M documentation can command a higher rate of return on their cognitive labor than their less E/M-savvy counterparts.  In other words if you know how to accurately bill for your services, there is a better chance you will get paid for what you really do.

E/M stands for “evaluation and management”.  E/M coding is the process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing.  CPT stands for “current procedural terminology.” These are the numeric codes which are submitted to insurers for payment.  Every billable procedure has its own individual CPT code.  

The CPT codes which describe physician-patient encounters are often referred to as “E/M codes”   There are different E/M codes for different types of encounters such as office visits or hospital visits.  Within each type of encounter, there are different levels of care.  For example, the 99214 code may be used to charge for an office visit with an established patient.  There are five levels of care for this type of encounter.  The 99214 code is often called a “level 4” office visit because the code ends in a “4” and also because it is the fourth “level of care” for that type of visit (with the 99215 being the fifth and highest level of care).  Each patient care encounter may be viewed as a unique procedure which requires specific documentation. 

The Key Components of E/M Documentation

The documentation for E/M services is based on three “key” components:

  1. History
  2. Physical Exam
  3. Medical Decision-Making

E/M University Coding Tip: The key components are used to satisfy the documentation requirements for E/M coding UNLESS the physician is coding based on TIME.  If time is the controlling factor, there are no specific documentation requirements for the three key components.

 The E/M key components can be thought of as the building blocks of documentation for all patient encounters.  Some types of encounters require complete documentation of all three key components, while others require only two out of three.

 The E/M Guidelines

The documentation requirements for each individual E/M code are dictated by a set of rules called the E/M guidelines.  The E/M guidelines were developed by the Center for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association.  Two versions have been released—the first in 1995 and the last in 1997.  

The Complete 1995 and 1997 E/M guidelines may be downloaded by clicking here (1995) and here (1997).

For a more detailed discussion about which version may be best for you,  click here.

The E/M guidelines define the requirements for individual E/M codes based on the extent of the documentation of the three key components. In general, higher paying E/M codes (like consultations or initial office visits) require more extensive documentation than lower paying codes (such as office visits with established patients or hospital progress notes).  

E/M University Coding Tip:The physician MUST choose to use EITHER the 1995 OR the 1997 E/M guidelines.  It is NOT acceptable to mix and match elements from both sets of rules within the body of the same note.

E/M University Coding Tip: The 1995 and 1997 E/M guidelines are practically identical when it comes to the key components of history and Medical Decision-Making.  The main difference between the two versions lies in the documentation required for the physical exam (see 1995 Vs. 1997 E/M guidelines).

E/M University Coding Tip: Due to increased flexibility for recording the HPI, most physicians should use the 1997 E/M guidelines for encounters where the patient has no spontaneous somatic complaints. 

The E/M guidelines define the requirements for individual E/M codes based on the extent of the documentation of the three key components. In general, higher paying E/M codes (like consultations or initial office visits) require more extensive documentation than lower paying codes (such as office visits with established patients or hospital progress notes).  In order to understand E/M coding, it is first necessary to understand each of the individual key components which are explained in our tutorial.

Peter R. Jensen, MD, CPC

The E/M University Video Tutorials

The Basic Course
Rational Physician Coding for E/M Services
Rational Physician Coding for Hospitalist E/M Services
Basic   RPC   Hospitalist
Basic Course Preview
Hospitalist Preview
H&P Preview
This course teaches you everything you need to know about the 1995 and 1997 E/M guidelines. Learn how to document the history and physical exam and how to quanitfy your medical decision-making. You are probably over-documenting!   Learn how to select the "correct" level of care for every encounter based on the cognitive labor provided. Then perform and document the history and exam in a purpose-driven manner to ensure compliance.   This is the version of the "Rational Physician Coding" course designed for hospitalists. See how to quantify your cognitive labor and perform and document the most common hospitalist encounters as efficiently as possible.
Established Office Patients
New Office Patients
Admission H&Ps
Established Office Patients   New Office Patients   HandP
Progress Notes Preview
Consult Course Preview
Critical Care Course Preview
These are the most common patient encounters on the planet, so it's important to code correctly for these visits. Knowing the difference between a level 3 and level 4 established office patient can make a huge difference in your remibursement and income.   Now that the consult codes have been eliminated for Medicare patients, the new office patient visit has become the most common outpatient initial encounter. Learn exactly what needs to be documented for each level of care for these visits. All levels of care are discussed.   Step-by-step, learn how to perform and document the key components correctly for all three levels of care for admission H&Ps. You will also see how to avoid the most common catastrophic documentation errors for these visits.
Hospital Progress Notes
E/M Consult Services
Observation Care Services
Progress   Consult   Obs
ER Preview
Faculty Course Preview
Observation Course Preview
These are the most common hospital encounters. Most doctors over-document and under-code for these services. This course will show you how to avoid this trap and save time while increasing reimbursement.   Although Medicare no longer pays for consult services, some private payers still do. But beware. Auditors love to downcode these visits when doctors don't include the exact right terminology. Learn to get it right.   The observation rules have recently been changed. Did you know there is a whole new set of codes for observation "progress notes?" See when to use the observation codes and how to complete the documentation correctly.
Critical Care and Other Timed Services
Observation Care Services
The Faculty Course
Critical Care   ER Visits   Faculty Course
ER Preview   ER Preview   ER Preview
What is critical care? What needs to be documented? What is needed for prolonged services? Using real-life examples, you will get the answers to these questions and more from this course.   You spend a lot of time in the ER so you might as well get paid for it. Emergency room visits are not just for ER docs any more! Hospitalists now have to use these codes when performing "consults" on patients in the ER.   The rules are a little different for documenting E/M services while working with medical students, interns and residents. Learn how house staff can help you complete the documentation for academic E/M services.
The Resident E/M Coding Course
    The Resident Course    
    ER Preview    
    Most academic programs provide little if any E/M coding education which leaves residents at a disadvantage when they get out in to the real world. This course teaches efficient E/M coding and documentation from the house-staff point of view.    



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