By Eric S. Fishman, MD
EHR Scope, LLC dba


This document is intended to provide an overview of the guidelines that are used by physicians and auditors to determine the level of evaluation and management service provided during patient encounters. We will review both the complex nature of the rules as well as how electronic health records can assist physicians and their staff with the task of determining the level of service. We will also provide detailed information designed to assist clinicians with evaluating how well electronic health record applications perform automated evaluation and management coding services. Please note, however, that the information contained herein should not be used to determine the actual level of service for an encounter. This should be based upon the 1995 and 1997 Evaluation and Management Documentation Guidelines published by the Center for Medicare and Medicaid Services as well as the Current Procedural Terminology book, published by the American Medical Association, and as are updated from time to time..


In an effort to improve medical documentation, the Centers for Medicare and Medicaid Services (CMS) (formerly the Health Care Financing Administration) expanded the documentation guidelines for evaluation and management (E&M) services in 1995 and again in 1997 1,2. These documents are both currently in effect and provide the basis for chart audits by CMS and other billing agencies.

The number one source of physician income in the United States is the fees attached to the E&M Current Procedural Terminology codes. The rules surrounding how to determine which E&M code to use for a specific encounter are complex. Choosing a code and billing at a fee that is not supported by documentation can result is severe sanctions and financial penalties. These two factors have resulted in a tendency to choose a code that is lower than what would be appropriate for a specific encounter. Electronic Health Records ( EHR ) have played a significant role in improving coding accuracy by improving documentation and through the automatic calculation of the level of service. In this document, we will review what type of documentation is needed to support a specific E&M code, and how electronic health records can assist in making this determination.

The Clinical History

There are three components to the Clinical History:

  1. History of Present Illness (HPI)
  2. Past Medical, Family, and Social History (PMH, FH, SH)
  3. Review of Systems (ROS)

The History of Present Illness

The level of HPI documented may be determined by either of two methods:

  1. The number of HPI elements that are needed to characterize the clinical condition, and are included in the document. The possible elements are: duration, severity, location, quality, timing, context, associated signs and symptoms, and modifying factors.
    • When the document is scored by this method, one of two HPI levels may be chosen:
      • A brief HPI: This consists of an HPI that contains one to three elements. e.g., “Three day history of severe headache” captures duration, location and severity. If no additional elements are documented, then this would be regarded as a brief HPI.
      • An extended HPI: This consists of an HPI that contains 4 or more elements. e.g., “Three day history of severe, throbbing headache with associated photophobia” records duration, location, quality, severity and associated signs and symptoms.
  2. The second method of determining the level of HPI does not include analysis of the HPI elements above, but rather is used when the HPI contains “the status of at least three chronic or inactive conditions.1” In this situation; the HPI is considered to be at the extended level. The following is an example of an HPI that contains three chronic conditions and their statuses:

Example: The patient has a history of diabetes, hypertension, and hyperlipidemia. Her blood sugars have been well-controlled on diet and oral hypoglycemic agents. The patient’s blood pressures have fluctuated significantly based on the patient diary and are suboptimally controlled on her current regimen. The patient’s most recent LDL was less than 100 and the patient is currently taking 40 mg of Lipitor per day.

The Past, Family, and Social History (PFSH)

There are three components to the PFSH1:

  • The past history: “the patient’s past experiences with illnesses, operations, injuries and treatments1”
  • The family history: “a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk”
  • The social history: “an age appropriate review of past and current activities”

There are two potential levels for these sections: pertinent and complete. A pertinent PFSH contains at least one type of history. A complete PFSH may require two or three types of histories, depending on the type of service provided. For example, a new patient evaluation requires that all three areas be documented before it can be scored as a complete PFSH.

The Review of Systems (ROS)

The review of systems is an “inventory” of body systems where the patient is asked to report signs or symptoms they are currently having or have had in the past. The recognized systems include constitutional, eyes, ears nose mouth and throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurological, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic.

This information may either be documented in the history of present illness or in a section titled review of systems. There are three levels of ROS used for scoring purposes. The first is a problem pertinent ROS that is limited to symptoms that are dealt with in the HPI. If between two and nine systems are reviewed, the ROS is scored as extended. If 10 or more systems are reviewed the ROS is scored as complete. The ROS is also considered to be complete if the systems with pertinent positives or negative are documents and there is “a notation indicating all other systems are negative…”

These rules may be difficult to remember, and the history is only one of the three components taken into consideration when determining the final code. For example, for a new patient evaluation or consultation, to reach a level 4 (e.g., 99204) the history must contain:

  • an extended HPI (4 HPI elements or three chronic conditions with statuses); and,
  • a complete PFSH (all three areas documented); and,
  • information from 10 or more ROS systems.

For an established patient visit, only a detailed history is needed to obtain a level 99214 level of service. One pattern of documentation that would meet this requirement would be:

  • an extended HPI
  • one item in the PFSH
  • information from 2 or more ROS systems.

Since most encounters are a mix of all three components in differing levels of detail, and it may be difficult for providers to retain the rules in memory, electronic health records can assist in this endeavor, as they can usually reliably record which details of the history are added and calculate the score for the history section.

The Physical Examination (PE)

As noted above, CMS expanded the documentation guidelines in 1995 and again in 1997. Both guidelines are currently in effect and differ very little other than in the physical examination. Auditors have been instructed to use either the 1995 or 1997 guidelines when determining the level of service, whichever is most advantageous to the provider.

Both sets of guidelines recognize four types of examination:

  • Problem focused (a limited examination of the affected body area or organ system)
  • Expanded Problem Focused (a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
  • Detailed — an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
  • Comprehensive — a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).

The 1995 Guidelines list the following as “Body Areas:”

  • Head, including the face
  • Neck
  • Chest, including breasts and axillae
  • Abdomen
  • Genitalia, groin, buttocks
  • Back, including spine
  • Each extremity

The following are listed as “Organ Systems:”

  • Constitutional (e.g., vital signs, general appearance)
  • Eyes
  • Ears, nose, mouth and throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Skin Neurologic
  • Psychiatric
  • Hematologic/lymphatic/immunologic

In order to encourage more detailed documentation that would better support the level of service billed, the 1997 Guidelines were created. They detail what information is needed at a much more granular level in the form of “bullets” (e.g., auscultation of heart). They also divided the physical examination into a general multi-system examination and 11 separate single organ system examinations: Cardiovascular; Ears, nose, mouth, and throat; Eyes; Genitourinary — female; Genitourinary — male; Hematologic/lymphatic/immunologic; Musculoskeletal; Neurological; Psychiatric; Respiratory; and Skin. Determining the level of service became even more complicated as a specific pattern of bullets unique to each examination type is required to determine whether the examination is problem focused, expanded problem focused, detailed, or comprehensive. Specific “scoring” rules are provided for each single organ system examination. In general, for a comprehensive examination, a specific pattern of bullets in “shaded” and “un-shaded” boxes is needed from the single organ system examinations. For a detailed examination, 12 or more bullets must be recorded. For an expanded problem focused examination, 6 or more bullets are needed, and for a problem focused examination, one to five bullets must be documented 1.2.

Electronic health records are particularly helpful when the 1997 guidelines are used to determine the level of service. Relatively simple algorithms can compute the bullets with identified information and inform the user of the type of examination (e.g., detailed) that has been documented.

Complexity of Medical Decision Making

The levels of E&M service recognized in CPT for complexity of medical decision-making include: Straightforward, low complexity, moderate complexity, and high complexity. There are three components that are used to determine the level of service:

  • The number of diagnoses (including “rule-outs”) and the number of management options that must be considered. The following point system is used to make this determination on a per diagnosis basis:
    • Self-limited or minor (1 point) (maximum two points allowed)
    • Established problem, stable or improved (1 point)
    • Established problem, worsening (2 points)
    • new problem (to examining physician), no additional workup planned (3 points) (maximum three points allowed)
    • new problem (to examining physician), additional workup planned (4 points)
  • In order to support this, the following information should be documented as appropriate:
    • the status of the problem(s)
    • the diagnoses considered (e.g., rule out)
    • initiation or changes in treatment, including therapies and instructions
    • referrals
  • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed. There are four levels: Minimal, limited, multiple, and extensive that are determined by a point system. The following items should be documented as appropriate:
    • diagnostic services ordered or performed during the encounter (1 point)
    • the results of diagnostic studies reviewed during the visit (1 point)
    • the decision to obtain additional information from another source such as old records or family members (1 point)
    • the results of a discussion held with another physician who performed a diagnostic study (1 point)
    • pertinent findings obtained from the review of old records or from additional history obtained from other sources such as family members (2 points)
    • direct visualization and independent interpretation of an image, tracing, or specimen that had been previously interpreted by another physician (2 points)
  • The risk of significant complications, morbidity, and/or mortality, as well as co-morbidities, associated with the patient’s presenting problems, the diagnostic procedures and/or the possible management options. The determination of risk is complex3 and rather than using a point system clinical examples are provided in tables contained within the CMS E&M guidelines in each of the following areas.
    • level of risk associated with the presenting problems.
    • level of risk associated with the diagnostic procedures that have been ordered.
    • level of risk associated with the management options have been selected.
  • The highest risk in any one of the above three categories is used to determine the overall risk.

The overall level of medical decision-making is determined by the highest two of the three above elements. For the number of diagnoses or treatment options and the amount/complexity of data reviewed the points are totaled. The maximum number of points allowed from each section is 4. As noted above, risk is calculated somewhat more subjectively.

For example, if the total number of points from both the number of diagnoses or treatment options and from the amount of data reviewed were three, and the risk was low, the level of complexity would be moderate.

Calculating the level of complexity is very difficult without the use of tables or algorithms. Electronic health records can assist this process greatly by identifying information generated during patient care that is relevant to complexity. Algorithms can then determine the level of complexity. Some areas such as the status of a condition and risk are more difficult to determine via algorithms, however once the data is entered the number of points and final level of complexity can quickly be determined.

Final Calculation of the Level of Service

For most encounters, the final determination of the level of service is made by summating the three components (history, physical, and complexity) or by using a time element. For some encounters (e.g., new patients) all three areas must have documentation in order to reach a higher level of service. For other encounters (e.g., established patients) the two highest levels, whether they be from the history, the physical examination or from complexity, are used to make the final determination.

The Role of Electronic Health Records

A high frequency of under-coding has been identified amongst primary care physicians, in particular for follow-up visits. This has been attributed to the complexity of the rules within the guidelines and concern over not having adequate documentation to support a higher level of service. EHRs have the potential of improving documentation and can automatically determine the appropriate level of service based on this documentation. This has resulted in fairly significant improvements in reimbursement for certain groups.

As the 1995 in 1997 CMS guidelines contain a great deal of information and a fair amount of complexity, an EHR that provides automated evaluation and management coding needs to undergo careful testing by experts. As the physician is ultimately responsible for the code assigned to the encounter, steps should be taken to ensure that the manufacturer has done their due diligence before purchasing a system. You may wish to inquire as to whether or not the suggested level of service generated by the system matches the level of service assigned by an auditor for the same document. We would suggest carefully comparing the coding level recommended by the EMR with your own opinion of the proper coding level, prior to submitting your bills.

Some Common E&M Codes

Encounter Level New Office Visit Revisit Consultation
Level 1 encounter 99201 99211 99241
Level 2 encounter 99202 99212 99242
Level 3 encounter 99203 99213 99243
Level 4 encounter 99204 99214 99244
Level 5 encounter 99205 99215 99245


  1. 1995 Documentation Guidelines For Evaluation & Management Services, Center For Medicare and Medicaid Services, 1995
  2. 1997 Documentation Guidelines For Evaluation & Management Services, Center For Medicare and Medicaid Services, 1995
  3. Grider, D. Medical Record Chart Analyzer, AMA Press, 2002
  4. Current Procedural Terminology, AMA Press, 2005

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