How to Figure Evaluation & Management Codes for Medical Billing

Determining the Proper Level of Service


There are many types of evaluation and management services. The most common types are new patient, established patient, consultation, and emergency room visits. New patient services refer to when a patient has never been seen by the physician, hasn't been seen in the last three years, or a new specialist in the same clinic has performed the procedure. Established patient visits refer to when the patient has been treated by the physician. Consultations require a physician to document a request, reason, and response in the documentation. Emergency room visits take place in the emergency room.


The first section that a physician discusses with a patient is the history, including the history of the present illness, personal, family, and social history, and the review of systems. This information can be obtained face to face in oral form or via a paper form that the patient completes in the waiting room. The history is one of the major parts in an evaluation and management code, and the more detailed the history the more likely it is that the provider can justify a higher level code.


The second section of an evaluation and management session is the hands-on section, or physical examination. This can be an examination of body areas and/or organ systems. The more areas that a physician touches and examines, the more thorough and detailed the examination. The more thorough the examination is, the higher the level at which the physician can be reimbursed.


The last section of an evaluation and management session is the assessment and planning. This is where the physician determines the diagnosis, the management options to care for this diagnosis, and the risks involved in treating this diagnosis. Also involved is the review of medical records and research in formulating the decision about the diagnosis and formulating the plan. The more diagnoses, complex treatment, and higher the risk, the higher the reimbursement level the physician will be reimbursed.


Other factors can be contributing but not integral to the evaluation and management calculation. These are counseling, which is the amount of time spent counseling the patient on her condition; coordination of care, which is the amount of time the physician spends coordinating care among other physicians; and time, which is the total amount of time the physician spent with the patient.

Tips and Warnings

  • The 1995 and 1997 guidelines for Medicare have charts to help gauge the level of service that is appropriate to pay.
  • Evaluation and management codes (CPT codes 99201-99499) are the most commonly billed codes in medicine. These are the codes for every office visit/encounter a physician has with a patient. It is easy to upcode, that is, bill for a higher level of service than was performed. It is also common for insurance companies to question and try to downcode, or request to change the level of service on a bill. It is important to understand how the evaluation and management codes work so that you, who work in the billing office of the physician,can properly code the bill and work with insurance companies to get the bill paid appropriately.