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E/M Levels 2, 3 and 4 Established Patient Visits
A Distinction with a Difference
Statistically, the overwhelming majority of patient office Unless symptoms persist, the patient is to return to the visits are billed at E/M Levels 2, 3 or 4. Determining office in two weeks for follow-up. The patient’s which billing level is correct for a particular patient neurologist, Dr. Banks, will be advised of the results of this encounter can often be a problem. This is particularly the case because many physicians mistakenly believe that the E/M Level 2, 3 or 4?
E/M level of service is determined by the amount of time What E/M level of service should be billed for this spent with the patient. In fact, it is not the time but the encounter? How does the physician documentation in the content of the physician chart documentation that patient record translate into the appropriate all based on the patient encounter outlined history, physical examination and medical decision making. For established patients, two documented in different ways, will result in of these three key components must be met or different E/M levels of service. As you will see, the presence or absence of explicit, service billed. The following case study illustrates how a particular patient visit could documentation has a direct impact on E/M code be billed at Level 2, 3 or 4 depending upon physician assignment. In order
to fully understand the
distinctions between the levels, each example should be
Case Study
read carefully and thoroughly before proceeding to the
A sixty-eight year old established patient with a past next one.
medical history of hypertension presents to a physician’s The examples include case analyses explaining how the office with a chief complaint of nausea and vomiting for 3 key components of history, physical examination and four days. The patient was recently discharged from the medical decision making are evaluated in determining the hospital and started on Sinemet 25/100 2 tabs TID for a appropriate E/M level of service under both the 1995 and new onset of Parkinson’s disease. In addition to nausea 1997 HCFA guidelines. The patient’s history, at the very and vomiting, the patient also complains of dull abdominal minimum, must include a chief complaint along with a pain and decreased desire to eat or drink.
history of present illness (HPI). The elements of an HPI Taking note of these complaints, the physician asks if the include a description of the chief complaint’s location, patient has experienced any acute neurological changes, quality, severity, timing, duration, context, modifying such as dizziness, headaches, seizures, recent falls or factors and associated signs and symptoms. The physical blurry vision, or has had any fever since his recent examination must conform to either the 1995 examination discharge. Patient denies having any of these additional guidelines or the 1997 general multi-system/single symptoms, but does mention that he has some difficulty specialty examination formats. In addition, to support a given level of service, medical decision making must be The physician then performs a physical examination, sufficiently documented in terms of the complexity of noting that the patient is a sixty-eight year old male, in no establishing a diagnosis, the number and severity of the apparent distress. Vital signs are BP 130/80, P 80, T 98.
conditions evaluated and the associated risk to the patient.
The lungs are found to be clear to auscultation and (See “Documentation Requirements for Established percussion. Heart rate was regular with no arrhythmia or Patient Office Visits for E/M Levels 2, 3 & 4” and “1997 murmur. Abdomen was palpated and noted to be soft, without tenderness or distention, with positive bowel By comparing each sample patient record to the corresponding case analysis, you will understand that the After examining the patient, the physician’s assessment completeness of your documentation of at least 2 of the 3 is that the nausea and vomiting are due to an inability to key components determines the level of billable service.
tolerate the initial dosage of Sinemet. The patient is The differences in documentation from example to instructed to decrease his Sinemet from 2 tabs to 1 tab example are printed in bold, underlined type. Depending three times a day, drink plenty of fluids, and continue upon the physician documentation, this patient encounter taking his antihypertensive medication since his blood would be billed at either Level 2, Level 3 or Level 4.
pressure has been stable and well controlled.
PATIENT RECORD: EXAMPLE #1
PATIENT RECORD: EXAMPLE #2
HPI: Nausea and vomiting with abdominal pain for 4 days.
HPI: Nausea and vomiting with dull abdominal pain and
On Sinemet for new onset of Parkinson’s.
decreased P.O. intake for 4 days. On Sinemet for new
onset of Parkinson’s.
PE: WNWD 68 year old male NAD
VS: 130/80 80 98
Imp: Nausea and vomiting due to Sinemet, Parkinson’s, HTN Resp: CTA & P
Plan: Decrease Sinemet to 25/100 1 Tab TID Heart: RRR
Imp: Nausea and vomiting due to Sinemet, Parkinson’s, HTN Continue HTN meds.
Return to office in 2 weeks.
Plan: Decrease Sinemet to 25/100 1 Tab TID D/W Dr. Banks, pt’s neurologistEncourage P.O. Continue HTN meds.
Return to office in 2 weeks.
CASE ANALYSIS: LEVEL 2 E/M CODE 99212
CASE ANALYSIS: LEVEL 3 E/M CODE 99213
History: Problem Focused
History: Problem Focused
In this case, the physician documented the chief complaint The HPI in this example has been extended to include the and 3 HPI elements (location: abdominal; duration: 4 days;
elements of quality (dull) and associated signs and symptoms
and context: nausea and vomiting due to Sinemet). However,
(decreased P.O. intake), in addition to the 3 elements the physician has failed to document the review of systems documented in Example 1 (location, duration and context).
(patient’s denial of a recent history of dizziness, headaches, However, failure to document a review of systems again results seizures, blurry vision or fever). Regardless of the amount of in the history remaining at the problem focused level. Had the documentation in other areas, without a “review of systems” physician documented the patient’s denial of dizziness, the level of history cannot rise above the problem focused level.
headaches, seizures, blurry vision or fever (a review of 3 Had the documentation been complete, the physician could systems), this record would have supported a detailed history.
claim credit for reviewing 3 systems (neurological, eyes and Physical Examination:
1995 Expanded Problem Focused: A limited examination
Physical Examination:
of the affected organ system (gastrointestinal) and 3 other 1995 Problem Focused: Only 1 organ system/body area
related organ systems (constitutional, respiratory, cardiovascu- (gastrointestinal) is documented. Exam was not extended to lar) was documented. This qualifies as an expanded problem include other related organ systems.
focused examination under the 1995 guidelines. 1997 Problem Focused: Only 1 element (palpation of
1997 Expanded Problem Focused: Six elements from the
abdomen) was documented from the general multi-system 1997 general multi-system exam were documented: examination. One to five documented elements from the 1997 constitutional (2), respiratory (2), cardiovascular (1), format is considered a problem focused examination.
gastrointestinal (1). Six to eleven elements are required for anExpanded Problem Focused exam.
Decision Making: Moderate Complexity
Decision Making: Moderate Complexity
Number of diagnoses to consider: Multiple (nausea/vomiting,hypertension, Parkinson’s disease).
Number of diagnoses to consider: Multiple (nausea/vomiting, Risk to patient: Moderate (adverse effects of treatment and hypertension, Parkinson’s disease).
Risk to patient: Moderate (adverse effects of treatment and prescription drug management).
Data to review: None.
Commentary:
In this case, the documentation supports only a Level 2 Commentary:
service. Even though there is decision making of moderate Since only 2 of the 3 key components are needed to validate complexity, the lack of thorough documentation of the other the level of service, the low level history can be eliminated and 2 key components (history and physical examination) prevents the 2 highest components (i.e., expanded problem focused billing at a higher level of service.
examination and moderate medical decision making) can be Note: Had the physician performed and documented a
used to support billing a Level 3 service.
review of just one pertinent body system, the history component would have become Expanded Problem Focused.
With an Expanded Problem Focused history and decision making of moderate complexity, the documentation would havesupported a Level 3 service.
PATIENT RECORD: EXAMPLE #3
HPI: Nausea and vomiting with dull abdominal pain and decreased P.O.
intake for 4 days. On Sinemet for new onset of Parkinson’s.
ROS: Denies HA, dizziness, sz, blurry vision, fever.
VS: 130/80 80 98Resp: CTA & PHeart: RRRAbd: soft, NT/ND, + BS Imp: Nausea and vomiting due to Sinemet, Parkinson’s, HTN Plan: Decrease Sinemet to 25/100 1 Tab TID D/W Dr. Banks, pt’s neurologistEncourage P.O.
Continue HTN meds.
Return to office in 2 weeks.
CASE ANALYSIS: LEVEL 4 E/M CODE 99214
History: Detailed
This detailed history includes 4 or more HPI elements (location, quality, duration, context, and associated signs and
symptoms); a review of at least 2 systems: neurological (denial of
headache, seizures, blurry vision), constitutional (denial of fever), and
eyes (denial of blurry vision); and 1 pertinent area of past medical, social
or family history (PMFSHx).
The significance of documenting all components of the history (i.e., HPI, ROS and PMFSHx) is illustrated in this example. Thishistory without a ROS would only be problem focused (see Example 2).
Physical Examination:
1995 Expanded Problem Focused: A limited examination of the
affected organ system (gastrointestinal) and 3 other related organ
systems (constitutional, respiratory, cardiovascular) was documented.
This qualifies as an expanded problem focused examination under the
1995 guidelines.
1997 Expanded Problem Focused: Six elements from the 1997
general multi-system exam were documented: constitutional (2),
respiratory (2), cardiovascular (1), gastrointestinal (1). Six to eleven
elements are required for an Expanded Problem Focused exam.
Decision Making: Moderate Complexity
Number of diagnoses to consider: Multiple (nausea/vomiting,
hypertension, Parkinson’s disease).
Risk to patient: Moderate (adverse effects of treatment and
prescription drug management).
Data to review: None.
Commentary:
This is an example of a well documented encounter that includes all of the necessary elements to support a detailed history. Since the 2 highest of the 3 key components can be used to support the level ofservice, the exam component can be eliminated. The detailed historyand moderate complexity decision making support billing at Level 4.

Source: http://www.nspo.com/userfiles/file/EMLevelsnarrative.pdf