How to define level of E & M services.

Components Used to Define Levels of E/M Services

The descriptors for the levels of E/M services recognize the following seven components that are used in defining the levels of E/M services:


* History
* Examination
*Medical decision making


* Counseling
* Coordination of care
* Nature of presenting problem

The first three components (history, examination, and medical decision making) are the key components in selecting the level of E/M services. Note that initial patient encounters (such as new office visit, initial hospital care, office consultations, and initial inpatient consultations) must meet or exceed the requirements for all three of the key components for the code selected.

The remaining encounters must meet or exceed the requirements for only two of the three components. An exception to this rule regarding the key components applies to visits that consist predominantly of counseling or coordination of care; for these services, time is the key or controlling factor to qualify for a particular level of E/M service. Stated differently, when counseling or coordination of care comprises more than 50 percent of the time involved in an E/M visit, then time may be used to determine code selection. Typical times are listed with the code descriptors in the E/M section of the CPT book.

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