The key components of an Evaluation and Management (E/M) service are history, exam and medical decision making, as well as contributory factors. Proper medical documentation will tell a story of the patient’s visit by recording pertinent facts, findings and observations. Payers will request your medical records to compare your billing (your choice of CPT and ICD-9 codes) with your documentation. They will check for site of service errors, the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided and accurate reporting of services provided.

Each office note has to tell a complete story (also referred to as “stand alone”). If auditors want to review your office note from Aug. 18, 2012, they will not look at your previous visit (or any other visit) unless you have referenced that visit in your note on August 18, 2012.


History can be broken down into three components:

  • History of Present Illness
  • Review of Systems
  • Past, Family and/or Social History


Two sets of official E/M guidelines are available:1995 Documentation Guidelines for Evaluation and Management Services and 1997 Documentation Guidelines for Evaluation and Management Services.

The 1997 guidelines provide more specific documentation requirements and have two types of exams to follow: General Multi-System Examination or Single Organ System examination.

Neither set of guidelines is better than the other. A clinician may choose which set of guidelines to use when determining the appropriate code for the level of service provided. For each separate E/M service, you must use only one set of E/M guidelines throughout the code determination process. Mixing or combining of the two sets of guidelines for a single E/M encounter are not acceptable. The 1997 Documentation Guidelines for Evaluation and Management Services provide more detail on the examination component, and the expected/recommended types of examination that should be completed for the respective levels. For example, these guidelines distinguish between a general multi-system exam and a single organ system exam.

Medical Decision Making

The levels of E/M services recognize four types of medical decision making: straight-forward, low complexity, moderate complexity and high complexity. Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

  • The number of possible diagnoses and/or the number of management options that must be considered
  • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed
  • The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.
  • Learn more about the documentation of the complexity of medical decision making.

Refer to your CPT book to determine the correct code you should use and what components are needed.


CPT codes for office or other Outpatient - New Patient (99201–99205) require all three components:

  1. History
  2. Examination
  3. Medical Decision Making

CPT codes for return hospital visits, Subsequent Hospital Care (99231–99233), require two of the three components:

  1. History
  2. Examination
  3. Medical Decision Making

Keep in mind that medical necessity will have to support the code you choose.

Hospital Discharge Services

These codes are based on time:

  • 99238: 30 minutes or less
  • 99239: more than 30 minutes

When billing for hospital discharge services, the amount of time it took to perform the service must be documented in the patient’s medical record for that day.

Documentation Tips

In addition to the components of an E/M service, there are several principles of medical documentation that must be considered:

  • The medical record should be complete and legible
  • The documentation for each patient encounter should include:
    • Reason for the encounter and relevant history, physical examination findings and prior diagnostic test results
    • Assessment, clinical impression or diagnosis
    • Plan for care
    • Date and legible identity of the observer
  • If not documented, the rationale for ordering diagnostic and other ancillary services should be able to be inferred easily
  • Past and present diagnoses should be accessible to the treating and/or consulting physician
  • Appropriate health risk factors should be identified
  • The patient’s progress, response to treatment, changes in treatment and revision of diagnosis should be documented
  • The CPT and ICD-9-CM codes reported on the claim form or billing statement should be supported by the documentation in the medical record

Additional Information and Resources