Testing Tips for Determining E/M Levels

Testing Tips for Determining E/M Levels

Certification exams can be stressful, but E/M leveling doesn’t have to make it worse.

By Colleen Mescall, MHA/E, CPC, CPC-I, CPMA, AAPC Fellow

Evaluation and management (E/M) coding can be intimidating for many people sitting for the Certified Professional Coder (CPC®) exam. How do you determine an E/M level when the level of the three key components are included in the test question scenario?

Begin with the Basics

An E/M level corresponds to the final number in an E/M service code. For example:

99201
Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making is a level 1 service;

99214
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity is a level 4 service;

The phrase “three of three” means the key components — history, exam, and medical decision-making (MDM) — must meet or exceed the requirements of the E/M code descriptor. The phrase “two of three” means two of the key components must meet or exceed the code requirements. For example, a new patient level 3 (99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity) requires three of three key components:

History – Detailed

Exam – Detailed

MDM– Low complexity

One method to help you calculate the correct E/M service level and code is to write the letters H, E, M (H = History, E = Exam, M = MDM), and — as you read the E/M questions in the exam — mark the level of each key component.

Example Question No. 1

A new patient comes to the internal medicine clinic today for diabetes, chronic constipation, arthritis, and a history of cardiac disease. The provider performs a detailed history, detailed exam, and MDM of moderate complexity. What CPT® code is reported?

You know the patient is new; therefore, you’ll need three of three key components to support a given service level.

History: detailed = supports a level 3 new patient service (e.g., 99203)

Exam: detailed = supports a level 3 new patient service

MDM: moderate = supports a level 4 new patient service (e.g., 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity)

In your test book or on paper, write it like this:

H: Det = 3

E: Det = 3

M: Mod = 4

In this case, because all three components must meet the code descriptor requirements, proper coding is 99203.

Example Question No. 2

An established patient comes to the internal medicine clinic today for diabetes, chronic constipation, arthritis, and a history of cardiac disease. The provider performs an expanded problem-focused history, expanded problem-focused exam, and MDM of moderate complexity. What CPT® code is reported?

You know the patient is established; therefore, you need two of three key components, as follows:

History: expanded problem-focused = supports a level 3 established patient service (e.g., 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity)

Exam: expanded problem-focused = supports a level 3 established patient service

MDM: moderate = supports a level 4 established patient service (e.g., 99214)

In this case, because you must have at least two components to support a service level, proper coding is 99213.

This method won’t help you to count the elements in the history, or the number of areas examined, but knowing how to quickly find the level of the individual key components can certainly take some of the pressure off.


Colleen Mescall, MHA/E, CPC, CPC-I, CPMA, AAPC Fellow, ICD-10 Instructor, has more
than 31 years of experience in the medical field, with a Masters in Health Administration and Education. She has worked in billing, coding, auditing, training, patient registration, and consulting in a variety of settings, including hospitals, group practices, and the Department of Defense. Mescall teaches coding and billing in Richmond, Va. She is the coding/billing manager for the emergency department at VCU Health. She is president of the Richmond, Va., local chapter.

One Response to “Testing Tips for Determining E/M Levels”

  1. Kim says:

    Please consider this….New patient where 3 of 3 apply…
    History- Comprehensive=4
    PE-Problem focused=1
    MDM-Moderate=4
    Despite limited PE, other key components are 4’s. How to appropriately draw this to conclusion? Please advise.
    Appreciate your expertise.

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