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Help! choosing the correct E/M

  1. Question Help! choosing the correct E/M
    Medical Coding Books
    I have taken my test serveral times and the E/M questions are a part of the test I have been having trouble with. I don't understand how to determine what level I should be chooosing....History, examination, and medical decision making. When reading the question, it may give you one or two of these but how do i determine if the third one fits or not? I have read the guidelines and anything i can find, but to no availe. If anyone knows any web sites, ro has any information that can assist me, it would be GREATLY appreciated. Thank you for taking the time to try to help in any way.

  2. #2
    Go to They have a free E/M coding tutorial. Great web site!

  3. #3
    Milwaukee WI
    Default History
    I'm not 100% certain of this, because I haven't seen a CPT test since 2005. But I believe (from a practice test I helped someone with last year) that the test questions will tell you what level of exam and MDM you have but rely on you to figure out the history from the information given.

    Look at your guidelines in your CPT book - you are looking for the heading titled Determine the Extent of History Obtained (in 2010 Professional edition, this is on page 9).

    Now, this doesn't give you specifics but you can write these notes in your book.

    Brief HPI = 1-3 elements (Timing, Duration, Location, Quality, Severity, Context, Modifying Factors, Associated Signs/Symptoms)
    Extended HPI = 4+ of the HPI elements recorded.

    Problem Pertinent ROS = just what it says, can be just 1 system
    Extended ROS = 2-9 systems reviewed
    Complete ROS = at least 10 of the 14 systems documented

    Pertinent PMFSH = at least 1 of these pertinent to the presenting problem
    Complete PMFSH = all three must be completed.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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