How To Use the Evaluation & Management (E&M) Codes Properly:

Part II: A Closer Look at E/M Guidelines

The Chiro.Org Blog

SOURCE:   Chiropractic Economics

By Kathy Mills Chang, MCS-P

Part II:   A Closer Look at
Evaluation & Management
(E&M) Guidelines

Jump to:   Part 1 or Part 3

Make sure you know how to fulfill the “examination” component. In part one of this series, the components of a patient’s history were reviewed, and you learned how it is the first of three elements that help you justify and document your evaluation and management (E/M) service. In the second part of this series, you’ll learn about the objective information required to properly document the examination.

Remember, the medical record establishes a chronological record of exams; tests and results; treatments; and treatment plans, including the diagnosis and prognosis of the illness or disease. Its job is to corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question.

For this reason, your medical record is a vital piece of the reimbursement puzzle, too. Understanding all the requirements, including those of the examination, is critical.

There are four levels of E/M services that are based on four types of examinations:

  1. Problem focused examination. This is a limited examination of the affected body area or organ system that the patient presented with.
  2. Expanded problem-focused examination. This is a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s).
  3. Detailed examination. This is an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area or organ system.
  4. Comprehensive examination. This is a general multisystem examination, or complete examination of a single organ system and any other symptomatic or related body area or organ system.

Centers for Medicare and Medicaid Services (CMS) has defined these types of examinations for general multisystem and the following single organ systems:

* Cardiovascular;
* Ears, nose, mouth, and throat;
* Eyes;
* Genitourinary (female);
* Genitourinary (male);
* Hematologic/lymphatic/immunologic;
* Musculoskeletal;
* Neurological;
* Psychiatric;
* Respiratory; and
* Skin.

A general multisystem examination or a single organ system examination may be performed by any physician regardless of specialty. The type (general multisystem or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgment, the patient’s history, and the nature of the presenting problem(s).

The musculoskeletal examination

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