Abstract
Evaluation and management services or E/M is a service used by private health insurance companies, Medicare and Medicaid for the purpose of reimbursement to providers for patient encounters within the United States. E/M is used in determining the type and extent of the condition of a patient. Current Procedural Terminology (CPT) Codes are used in conjunction with E/M codes to document and bill for reimbursement of specific services.

Evaluation and Management Services
To determine the level of evaluation and management services that are provided to a patient, the key components and contributing factors need to be assessed. The procedure would be to identify if the patient is a new or established patient, where the patient is being seen, is this a consultation, is the patient being seen for an illness or preventive care, determine the level of history, the level of examination, the level of medical decision making (MDM), then assign the proper code (Abraham, 2011).
Evaluation and management service levels are based on any and all documentation found in a patient’s medical record. There are different levels of service for which key components are based on; history, examination and medical decision making. These three components are a reflection of what occurred and is recorded by the doctor in the patient’s medical record. You will find these key components in every patients case with the exception of counseling encounters. By using these key components, you are able to decide what level of service to use (Abraham, 2011).
History is what the patient tells the doctor, There are four elements of a history; Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), and Past, Family, and/or Social History (PFSH). By reading notes the doctor has written in the medical record, a coder would be able to identify the elements and levels of a history. Knowing what we know about the history of the patient we move on to the various levels of Examination (Buck, 2010).
The examination may involve the body area (BA) or the organ system (OS), to properly code, the type and extent of what occurred is needed. Problem Focused, Expanded Problem Focused, Detailed and Comprehensive are the levels of examination, this is the part of the patients visit where the physician determines the nature of the presenting problem (Buck, 2010).
There are four types of Medical Decision Making (MDM) services; Straight-forward complexity, Low complexity, Moderate complexity and High complexity. This service refers to the difficulty in establishing a diagnosis or a management option which is usually determined by a consideration of the decision making process. Complexity of these decisions are based on three important elements; number of diagnosis, amount of complexity of data to review and the risk of complication or death (Abraham, 2011).
All three components are needed to properly document new patient encounters, consultations, ER visits and admissions. If an established patient makes daily hospital or outpatient visits then only two of the three key components need to be assigned. So when assigning a code there must be 2 of 3 key components documented to use that specific code (Buck, 2010). Example of a key component would be an office or other outpatient visit, evaluate established patient; would need 2 out of 3 of these components- a detailed history, a detailed examination or medical decision making (code 99214).
Contributory factors (counseling, coordination of care and nature of presenting problems) are the three conditions that aid the physicians in determining the extent of the key components that are necessary to treat a patient, but are not always a consideration in every case (Abraham, 2011). Example: A patient presents with leg pain from an accident and also complaints of leg numbness off and on. This counts as location (leg), context (accident), and associated signs and symptoms (numbness) but not timing (off and on) (off and on refers to timing related to the numbness, not the leg pain).
References
Abraham, M., Ahlman, J., Boudreau, A., Connelly, J., Evans, D., & Glenn. R., (2011). Current procedural terminology (CPT) Standard. Illinois: American Medical Association
Buck, C., & Thurston, S., (2010). Step-by step medical coding. Missouri: Saunders