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About Evaluation & Management in Medical Coding

Evaluation and Management codes are very common codes in the medical coding industry. They fall in the CPT code range of 99201-99499, and represent services rendered by a physician based on the amount of components performed during the office visit.

  1. History of Present Illness

    • The first component is the history of present illness. This is where the patient explains and discusses her symptoms with the physician or nurse.

    PFSH

    • The PFSH is Personal, Family, and Social History. This is the component where the patient reveals his complete medical history to the physician. The patient's family history, and diseases that can have hereditary components are also discussed, as is the patient’s social history, which is a look at things such as living situation, smoking, drinking and drug history.

    ROS

    • The ROS is the Review of Systems. The patient answers questions about various areas of his body, to help the doctor determine if he has had unusual symptoms in those areas that could be contributing to the condition that prompted his visit.

    Physical Examination

    • The physical examination can either be of the organ systems, or of body regions. The more systems or regions the physician physically touches, the higher is the level of office evaluation for which he can be reimbursed.

    Medical Decision Making

    • Medical decision making is made up of the assessment and plan. This is the physician's diagnosis of the patient's condition, and his plan to treat it.

    Time, Counseling, Coordination of Care

    • There are three other components that may be considered when calculating an evaluation and management level: the time the physician spends with the patient, the counseling of the patient by the physician, and the physician’s coordination with other providers concerning the patient's treatment.

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