Access to the PPM Journal and newsletters is FREE for clinicians.
9 Articles in Volume 8, Issue #1
Spine-related Pain in Sports Medicine
Outpatient Interventional Treatments for Migraines and Pain Flare-ups
Identifying Abusers Prior to Initiating Chronic Opioid Therapy
Urine Drug Tests in a Private Chronic Pain Practice
Platelet Rich Plasma (PRP) Matrix Grafts
Role of Sustained-release Opioids in Treating Chronic Pain
Adenoid Cystic Carcinoma of the Parotid Gland
Evaluation and Management Codes Drive Medical Necessity
Grappling with the Ethics of Practical Pain Management

Evaluation and Management Codes Drive Medical Necessity

The 2008 Work Plan was issued by the Office of Inspector General (OIG) on October 1, 2007 (http://oig.hhs.gov/08/Work_ Plan_FY_2008.pdf). It outlines primary areas that its Office of Audit Services and Office of Evaluations and Inspections will be targeting in 2008—including Medicare Payments for Interventional Pain Management Procedures. The fact is that Medicare and all insurances will increase their examination of your documentation practices for “medical necessity” in 2008. In order to meet such guidelines, you will have to get serious about computerizing your practice with an appropriate pain management–specific EMR system having a proven track record in helping pain management doctors—as opposed to primary care doctors—document medical necessity. The following article by Dr. Ted Arkfeld will help you determine what you need to do in order to document the medical necessity that is crucial for you to be paid for your services.

In the last article, I discussed medical necessity since the OIG 2008 Work plan will focus on pain management clinics. Medical necessity definitions vary from one payer to the next. Fortunately, Medicare—and most Blue Cross and Blue Shield plans—publish their definitions. However, this is not always the case with other group insurances and often lead to high levels of frustration from providers and their billing departments. No matter what their definition may be, if your E/M codes are chosen correctly, you can begin the process of establishing medical necessity.

For some reason, E/M coding remains a misunderstood process, and may lead to downcoding or upcoding to an inappropriate higher level than the documentation can validate. If you are still using exam forms or writing out the history and examination findings in long hand, then you are working way too hard and probably losing insurance reimbursements due to improper coding. Even if you have an electronic medical record system (EMR), you may still be losing revenue since most of these programs let you choose the level of E/M after you have completed the history and examination sections. The problem with these EMR’s is that they are at the back end of the process instead of guiding you from the start through a preset compliant workflow to insure the correct level is reached.

Before we delve into EMR system selection, you still need to understand how to arrive at the appropriate E/M level, and this starts with what constitutes a new, versus established, patient visit.

New and Established Patient Definitions

New Patient. A new patient is one who has not received any professional services from a physician or another physician of the same specialty who belongs to the same group practice, within the past three years

Established Patient. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

Who is Not a New Patient?


  1. Someone who has seen another physician in a group practice of a different specialty, but all physicians use the same tax identification number.
  2. A patient who was previously under care, but who is now involved in either an auto or worker’s compensation case.
  3. Any patient who has been under your care or another physician in your group within the past three years, no matter if they have a new injury or new insurance.

I know this seems pretty straightforward, but unfortunately there has been incorrect information relayed regarding these two very distinct classifications.

Okay, so now you have a clear definition of a new patient and one is waiting right now to be seen by you. What is your next step? How are you currently deciding on what level to go with? Hopefully, you are not basing this decision on time. More on that later, but for now there are five E/M levels, each with subcategories that must be met or exceeded to arrive at the correct coding decision. This is where an EMR system that allows you to proceed with a up front workflow procedure is a must.

E/M Components

The components of E/M are listed below with the first three being key:

1.  History Key
2.  Examination Key
3.  Medical Decision Making Key
4.  Counseling Contributory
5.  Coordination of Care Contributory
6.  Nature of Presenting Problem Contributory
7.  Time Contributory

Each one of these E/M components has subcategories that need to be satisfied in order to meet or exceed a certain level. These subcategories are as follows:

  • Problem Focused
  • Expanded Problem Focused
  • Detailed
  • Comprehensive

History Criteria

History of Present Illness (HPI):

  1. Location
  2. Quality
  3. Severity
  4. Timing
  5. Duration
  6. Context
  7. Mod. Factors
  8. Sign/Symptoms

Review of Systems (ROS):

  1. Constitutional
  2. Eyes
  3. Ears/Nose/Mouth/Throat
  4. Cardiovascular
  5. Respiratory
  6. Gastrointestinal
  7. Genitourinary
  8. Musculoskeletal
  9. Skin
  10. Neurological
  11. Psychiatric
  12. Endocrine
  13. Hematologic/Lymphatic
  14. Allergic/Immunologic

Review of systems must be problem pertinent.
Past Medical, Family & Social History (PFS):

  1. Past Medical History
  2. Family History
  3. Social History

Examination Criteria


  • Three Vital Signs
  • General Appearance


  • Conjunctiva, lids
  • Pupils, irises
  • Opthalmoscopic exam


  • Ext. ears, nose
  • Ext. aud canals, TM’s
  • Hearing assessment
  • Nasal mucosa/septum/turbinates
  • Lips, teeth, gums
  • Oropharynx exam


  • Masses, appearance
  • Thyroid


  • Respiratory effort
  • Percussion of Chest
  • Palpation of Chest
  • Auscultation of lungs


  • Palpation of heart
  • Auscultation of heart
  • Carotid Arteries
  • Abdominal aorta
  • Femoral arteries
  • Pedal pulses
  • Extremities for edema/varicosities

Chest (Breast)

  • Inspection of Breasts
  • Palpation of breast/axillae


  • Mass/tenderness
  • Liver & Spleen
  • Hernia
  • Anus/Rectum
  • Stool Sample (if indicated)


  • Scrotum
  • Penis
  • Prostate
  • Ext. genitalia
  • Urethra
  • Bladder
  • Cervix
  • Uterus
  • Adnexa

Lymphatic (two or more areas required)

  • Neck
  • Axillae
  • Groin
  • Other


  • Gait, station
  • Digits, nails
  • Joints, bones, muscles for each of 6 areas: head/neck, spine/ribs/ pelvis, RUE, LUE, RLE, LLE
  • Inspection/palpation
  • Range of motion
  • Stability/dislocation
  • Muscle strength, tone


  • Inspection rashes, lesions
  • Palpation nodules, tightness


  • Test Cranial Nerves
  • Deep Tendon Reflexes
  • Sensation


  • Judgment, insight
  • Oriented to person, place, and time
  • Recent, remote memory
  • Mood and effect
  Problem Focused Ex. Prob Foc Detailed Comprehensive
HPI 1-3 Elements-brief 1-3 Elements brief 4+ Elements 4+ Elements
ROS No ROS needed 1 ROS Needed 2-9 ROS 10+ ROS
PFSH No PFS History No PFS History 1 review PFS 2 relevant PFS
Problem Focused: 1-5 elements in 1+ BA/OS
Exp. Problem Focused: 6 elements in 1+BA/OS
Detailed: 6 BA/OS, 2 elements each or
12 elements in 2+ BA/OS
Comprehensive: 9 BA/OS, all elements or 2+ of each
Elements = the total number of bullets examined and documented. Must be problem pertinent.
BA = Body Areas
OS = Organ Systems
Total Bullets: Male–54, Female–56

Medical Decision Making
In this E/M component, the subcategories may be either:

  • Straightforward
  • Low Complexity
  • Moderate Complexity
  • High Complexity

Of the following, two out of three need to be met:

    Straight-forward Low Moderate High
A. # of DX. Minimal Est. Prob Worsening New Problem New Prob
B. Amount/ Complexity of Data Reviewed Minimal Low Moderate 3 High 4
C. Risk of Complications Morbidity or Mortality Minimal Low Moderate High

Patient E/M Levels
New Patient
Level History Examination Medical Decision Time
99201 Prob Focused Prob Focused Straightforward 10 min
99202 Expanded PF Expanded PF Straightforward 20 min
99203 Detailed Detailed Low 30 min
99204 Comp Comp Moderate 45 min
99205 Comp Comp High 60 min
Established Patient
Level History Examination Medical Decision Time
99211 Physician presence not required 5 min
99212 Prob Focused Prob Focused Straightforward 10 min
99213 Expanded PF Expanded PF Low 15 min
99214 Detailed Detailed Moderate 25 min
99215 Comp Comp High 40 min
PF= Problem Focused
Comp= Comprehensive
Time= Approximates only

Deciding on E/M Level

So, how do you decide on the E/M level for your new patients? If you are still handwriting charts, do you have a flow chart that guides you through the information listed above? From the physician charts I have reviewed, the usage of time is predominantly used as the deciding factor. Unfortunately, many physicians incorrectly apply time in choosing the E/M level. Time is the least of all factors and, if used, there must be detailed documentation to support why this contributory component was utilized.


I realize all this information can seem very time consuming for a busy practice. However, I urge caution for those physicians who continue to base the E/M decisions on anything other than the criteria listed above. With Federal mandates stating all physician offices need to have electronic medical record systems by 2013, why continue to write in charts and take the chance of a post-payment audit? With the right EMR, the process of E/M coding and documentation for your new and established patients can be both compliant and document medical necessity. In the next article, I will further elaborate on the essential verbiage to support your services and procedures.

Last updated on: January 30, 2012
close X