Select proper evaluation/management levels to aid your practice

February 10, 2011

E/M coding can be quite logical once you understand all of the components, according to the author.

Q: I don't understand the difference between the levels of service for evaluation and management (E/M) codes, so I always choose the same code. What determines, for instance, an "expanded, problem-focused" history versus a "detailed" history, and how does that information apply to the level of service?

The basic elements for the visit and dictation are history, examination, and medical decision-making. Each of these key components has subparts that, when scored together, determine the naming convention under each E/M code.