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E/M codes are based on these three components: Extent of personal, family, and social history. Extent of examination. Complexity of medical decision making.
Curtis Strite
When coding E/M (Evaluation and Management) services, ensure that you select the appropriate level based on the complexity of the patient's condition and the extent of the history, examination, and medical decision-making involved. Document the encounter thoroughly to support the code chosen, and follow the guidelines provided by the American Medical Association's Current Procedural Terminology (CPT) manual and any relevant payer policies. Remember to code to the highest level of service supported by the documentation.
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