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Evaluation and management (E/M) services

What are evaluation and management (E/M) services? E/M services refer to diagnostic or therapeutic procedures furnished by physicians or non-physician practitioners (i.e., nurse practitioners, clinical nurse specialists, certified nurse midwives, and physician assistants). E/M services are the most common services billed by Medicare physicians.
How are E/M codes selected for the service performed? Billing Medicare for a patient visit requires the selection of the code that best represents the level of E/M service that was performed and effectively documented in the patient’s medical record. The E/M code selected must be supported by the medical documentation, which should indicate levels pertaining to the history, examination, and/or medical decision-making of the corresponding patient encounter.
Why are E/M services a focus for Medicare? Audit results from Medicare claim review programs (e.g., Comprehensive Error Rate Testing [CERT]) indicate that E/M services are often coded incorrectly, with providers either “upcoding” or “downcoding,” resulting in an increase to the percentage of improper payments made by the Medicare program.
News
View recently released E/M-related articles on the First Coast Service Options Inc. (First Coast) Medicare website.
Search the First Coast Medicare website for E/M-related articles.
Search First Coast’s Medicare B publications for previously-published E/M articles.
Medical Documentation
Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.
Tools
E/M interactive worksheet -- the E/M interactive worksheet helps take the guesswork out of “building a code” by automatically calculating a suggested E/M code based upon the user’s entries and preferred set of guidelines.
• E/M interactive worksheet: Help guide -- learn how to take advantage of the features of our exclusive E/M interactive worksheet and find the code that best represents the level of E/M services furnished during a patient’s visit.
Checklist: Evaluation and management documentation pdf file -- this checklist is an aid to assist providers when responding to medical record documentation requests pertaining to E/M services.
Tips and frequently asked questions (FAQs)
Evaluation and management (E/M) tips -- get tips on key components and documentation required when performing different types and levels of E/M services.
Evaluation and management (E/M) FAQs -- find answers to providers’ questions regarding E/M services.
E/M interactive worksheet FAQs -- discover answers to providers’ questions regarding how to use the E/M interactive worksheet.
Online learning
Explore online learning opportunities offered by First Coast University external link and take advantage of 24-hour access to free training that will fit your learning needs as well as your busy schedule. In addition, First Coast University offers several online courses that will help you better understand how to bill for E/M services.
06/13/12 recording: E/M coding and medical documentation: Errors and solutions (Part B) external link -- This webcast is for providers and their representatives responsible for selecting, documenting, or coding evaluation and management (E/M) services. This class will cover Medicare’s guidelines pertaining to the medical necessity of services rendered, documentation requirements for the key components of an E/M service, and tips to avoid common errors identified in the documentation of E/M services.
08/29/12 recording: E/M: Find the code that fits the service (Part B) external link -- This session will address the components and guidelines pertaining to Evaluation and Management (E/M) code level determination, using a higher-level documentation example to demonstrate how an E/M code is “constructed”. An online tool created by First Coast that will assist in this process will be applied.
09/19/12 recording: Avoid the trials and tribulations of E/M (Part B) external link -- This webcast covers Medicare’s guidelines pertaining to the medical necessity of services rendered, documentation requirements for the key components of an E/M service, and tips to avoid common errors identified in the documentation of E/M services.
Resources
Evaluation and Management Services Guide external pdf file -- this guide provides education on E/M services, including medical record documentation, E/M billing and coding considerations, and the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services.
Documentation Guidelines for Evaluation and Management Services -- two sets of official E/M guidelines are available. Use these guidelines to learn more about the specific steps for determining the levels for the key components of E/M services and their respective elements. A physician or practitioner may use either set of guidelines to determine the appropriate level of code for the E/M service provided; however, only one set of E/M guidelines may be used throughout the code determination process. Mixing or combining the two sets of guidelines for a single E/M encounter is not acceptable.
• 1995 Documentation Guidelines for Evaluation and Management Services external pdf file
• 1997 Documentation Guidelines for Evaluation and Management Services external pdf file
Evaluation and Management Services (E/M) fact sheet external pdf file -- this fact sheet describes common Comprehensive Error Rate Testing (CERT) program errors related to E/M services and provides information on the documentation needed to support a claim submitted for E/M services.
Clarification of Evaluation and Management (E/M) Payment Policy external pdf file -- Medicare Learning Network® article (MM7405) clarifies the use of E/M codes by providers for services in various settings.
Medicare Claims Processing Manual (IOM 100-04, Chapter 12, Section 30.6) external pdf file -- this section directly address Medicare’s guidelines pertaining to E/M and covers multiple types of codes, common issues and various scenarios involving use of E/M codes.
Related links
Comparative Billing Report (CBR) services external link -- a CBR is a documented analysis that shows a provider's billing pattern for various procedures or services and compares that billing to their peers.
Comprehensive Error Rate Testing (CERT) program -- the CERT program measures the paid claims error rate for Medicare claims to ensure that the Medicare program is paying claims correctly. The CERT program uses a random and a service-specific sampling of claims methodology, which includes E/M services.
Primary care incentive program (PCIP) -- the PCIP program pays incentives to providers who provide primary care services. Primary care providers are paid quarterly, an amount equal to 10 percent of the payment amount for such services paid under the physician fee schedule (PFS).
Physician quality reporting system (PQRS) -- the PQRS is a voluntary reporting program, which provides an incentive payment to practices with eligible professionals who satisfactorily report data on quality measures for covered physician fee schedule (PFS) services furnished to Medicare Part B fee-for-service (FFS).
Part B
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.