Evaluation & Management (E/M) Services
E/M codes describe the cognitive work of assessing and managing patients and are among the most frequently reported services in medicine. The 2021 revision of the office/outpatient guidelines fundamentally changed how these visits are leveled, and the CPC exam tests whether you understand the current rules — not the retired 1995/1997 bullet-counting approach.
Leveling office visits: time or MDM
For office and other outpatient E/M services (new and established patients), history and examination no longer drive the code. Instead, you select the level using EITHER total time on the date of the encounter (including the physician/QHP's face-to-face and non-face-to-face work such as chart review, ordering, and documentation) OR the level of medical decision making. History and exam are still performed and documented as medically appropriate, but they are no longer scored. This gives coders two independent pathways to the same code family.
The three elements of medical decision making
MDM is graded across three columns: (1) the number and complexity of problems addressed at the encounter; (2) the amount and/or complexity of data to be reviewed and analyzed — tests, external notes, independent interpretation of studies, and discussion with other providers; and (3) the risk of complications, morbidity, or mortality of patient management, including the risk of the treatment options considered. The overall MDM level (straightforward, low, moderate, high) is set by meeting or exceeding two of the three elements.
Essential E/M modifiers
Two modifiers appear constantly with E/M. Modifier -25 identifies a significant, separately identifiable E/M performed on the same day as a procedure or other service that carries its own inherent work — the E/M must stand on its own in the documentation. Modifier -57 identifies the E/M at which the decision for major surgery was made (the day before or day of a 90-day global procedure). Misusing -25 to force payment for routine pre-procedure evaluation is a frequent audit target.