Preparing to use the E/M interactive worksheet

Since the E/M worksheet is designed to be interactive, your selections will directly affect the calculation of the suggested E/M code. Therefore, before beginning your E/M interactive worksheet session, it is strongly recommended that you have the following available:

• Patient’s medical record
• 1995 Documentation guidelines for evaluation and management services
• 1997 Documentation guidelines for evaluation and management services
• AMA - 2021 CPT E/M office revisions: level of medical decision making table
• AMA guidance - office / outpatient visits on / after 1/1/21
• AMA CPT evaluation and management changes for 2023
• Current Procedural Terminology (CPT) manual

Note: Several of these resources and additional supporting information can be found by clicking on the "Helpful resources" informational icon at the top of the worksheet.

Enter patient information

Next, there is a requirement to specify the details of the encounter. Using the patient’s medical record as a reference, enter the following information:

• Beneficiary name
• Date of service (required)
• Service type (required)
• Chief complaint (CC) or purpose of the patient’s visit

Determining the level of E/M service

The E/M worksheet is designed to function based on the date of service and type of visit.

If the date of service is on and after January 1, 2021, and related to an office or outpatient services visit, the worksheet options are based on the AMA guidance for office / outpatient visits on / after 1/1/21 to determine the level of E/M service performed.

If not related to office or outpatient services, and the date of service is prior to January 1, 2023, the worksheet options are based on the 1995 or 1997 E/M guidelines.

If the date of service is on or after January 1, 2023, the worksheet options are based on the AMA 2023 E/M code and guideline changes for 2023.