Evaluation and management (E/M) services refer to visits furnished by physicians and qualified, licensed, non-physician practitioners. Billing Medicare for a patient visit requires the selection of the code that best represents the level of E/M service performed.
Since the 1995 and 1997 guidelines or AMA CPT E/M Code and guideline changes for 2021 and 2023 each specify different criteria to determine the level of E/M service performed, only one set of guidelines may be used to document a specific patient visit. For other E/M visit dates of service prior to January 1, 2023, this interactive
worksheet offers providers the option to select either their preferred set of guidelines (1995 or 1997) or to select both sets for the purpose of comparison.
To emphasize the importance of medical necessity when reporting E/M services consider the following: all E/M services reported to Medicare must be adequately documented so the medical necessity is clearly evident because federal law requires that Medicare not pay for services for which the documentation does not establish such. For E/M services medical necessity of a visit as well as the CPT “level” of the service must both be documented. Per the
CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, Section 30.6.1 A
"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported."
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