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Components of Evaluation and Management Coding

Components of Evaluation and Management Coding

The calculation of evaluation and management (E&M) code is based on the following components:

E&M Coding Component	Description
New Patient or Established Patient	Required. This component identifies which patient type is used for the overall E&M calculation. A new patient has not received any professional services from any physician in the same specialty within a group over the last three years.
Visit Type	Required. The visit type identifies the E&M code category, for example, Office Visit, Consultation Visit, or Preventive Visit. The visit type factors into all coding guidelines.
Reason for Visit (RFV) or Chief Complaint (CC)	Required. The RFV describes the symptom, problem, condition, or diagnosis that indicates why the patient has come for services. The RFV factors into the calculations under the 95 or 97 Coding Guidelines.
History of Present Illness (HPI)	The HPI factors into the calculations under the 95 or 97 Coding Guidelines and documents any of the following elements: Location Duration/Onset Timing/Frequency Severity/Status Quality Context Modifying Factors – Aggravated by and Relieved by elements Associated Symptoms/Pertinent Negatives Three or more Chronic Conditions with a documented Status Note: Not every encounter requires documentation of HPI elements, and not all HPI elements are relevant to the RFV.
Past Medical, Family, and Social History (PMFSH)	The PMFSH factors into the calculations under the 95 or 97 Coding Guidelines and documents the review and/or update of the patient’s histories as follows: Past – Medical and surgical history, review of current medications, immunization status, and allergies Family – Medical events in the patient’s family that are significant, for example: health status, cause of death of a family member, and/or any specific diseases or problems related to the RFV or that may place the patient at risk Social – An age-appropriate review of past and current social activities
Review of Systems (ROS) (also considered History)	The ROS factors into the calculations under the 95 or 97 Coding Guidelines and records an inventory of body systems obtained through questions seeking to identify signs and/or symptoms that help to further define the problem.
Physical Exam (PE)	Under the 95 Coding Guidelines, calculations are based on the number of documented body areas and organ systems. Under the 97 Coding Guidelines, calculations are based on specific documented elements for either a Multi-system exam or the ten Single-system exams.
Medical Decision Making (MDM)	MDM factors into the calculations for 95, 97, and 2021 Coding Guidelines and indicates the level of complexity of establishing a diagnosis and/or selecting a treatment plan.
Counseling	Under the 95 or 97 Coding Guidelines, counseling is the controlling factor for the calculation of time when more than 50% of the encounter time was spent counseling and/or coordinating care.
Time	Under the 2021 Coding Guidelines, the total time includes the face-to-face time with the patient and other time personally spent by the physician and/or other qualified health care professional on the day of the encounter, including counseling time. It is not required that more than 50% of the encounter time be spent counseling or coordinating care.