In-Depth Study Guide: Documentation Guidelines for Evaluation and

Management (E&M) Services

Overview

Both the 1995 and 1997 Documentation Guidelines for E&M services are essential tools for
healthcare providers to ensure correct documentation for billing purposes. They
emphasize the documentation of history, examination, and medical decision-making
(MDM), which are key components in deciding the proper E&M code. Understanding the
nuances of each set of guidelines and how to apply them can improve the coding process
and ensure compliance with billing regulations.
Key Components

History

o Elements:
 History of Present Illness (HPI): A detailed account of the development of
the patient's present illness.
 Brief: 1-3 elements of the HPI (e.g., location, quality, severity,
duration, timing, context, modifying factors, associated signs and
symptoms).
 Extended: 4 or more elements of the HPI or the status of at least 3
chronic or inactive conditions.
 Review of Systems (ROS): An inventory of body systems through a series of
questions to identify signs and/or symptoms the patient may be
experiencing.
 Problem Pertinent: System directly related to the problem(s)
identified in the HPI.
 Extended: System directly related to the problem(s) identified in the
HPI and a limited number of additional systems (2-9).
 Complete: System directly related to the problem(s) identified
in the HPI and all additional (10 or more) organ systems.
 Past, Family, and Social History (PFSH): A review of the patient's
past medical history, family medical history, and social history.
 Pertinent: At least one item from any of the three history
areas.
 Complete: A review of two or all three of the history areas,
depending on the level of service.
 For established patients, at least one specific item from
two of the three history areas must be documented.
 For new patients, at least one specific item from each of
the three history areas must be documented.
o Levels of History:
 Problem Focused: Brief HPI.
 Expanded Problem Focused: Brief HPI and problem pertinent ROS.
  Detailed: Extended HPI, extended ROS, and pertinent PFSH.
 Comprehensive: Extended HPI, complete ROS, and complete PFSH.

Examination

1995 Guidelines:

Body Areas:

 Head, including the face.

 Neck.
 Chest, including breasts and axillae.
 Abdomen.
 Genitalia, groin, buttocks.
 Back, including spine.
 Each extremity.

Organ Systems:

 Constitutional (e.g., vital signs, general appearance).

 Eyes.
 Ears, nose, mouth, and throat.
 Cardiovascular.
 Respiratory.
 Gastrointestinal.
 Genitourinary.
 Musculoskeletal.
 Skin.
 Neurologic.
 Psychiatric.
 Hematologic/lymphatic/immunologic.

Levels of Examination:

 Problem Focused: Limited examination of the affected body

area or organ system.
 Expanded Problem Focused: Limited examination of the
affected body area or organ system and other symptomatic or
related organ systems.
 Detailed: Extended examination of the affected body area(s)
and other symptomatic or related organ system(s).
 Comprehensive: Complete single system exam or complete
multi-system exam.

1997 Guidelines:
  Uses specific bullet points for each organ system and body area.

Levels of Examination:

 Problem Focused: 1-5 elements identified by a bullet.

 Expanded Problem Focused: At least 6 elements identified by
a bullet.
 Detailed: At least 12 elements identified by a bullet.
 Comprehensive: Perform all elements identified by a bullet in
at least 9 organ systems or body areas, and document at least 2
elements identified by a bullet in each of 9 areas/systems.

Three Key Components:

History
Examination
Medical Decision Making

Medical Decision Making (MDM)

Elements:

Number of Diagnoses or Management Options:

 Consider the number and complexity of problems addressed

during the encounter.

Amount and Complexity of Data to be Reviewed:

 Includes diagnostic tests, documents reviewed, and discussions

with other healthcare providers.

Risk of Complications, Morbidity, and Mortality:

 Based on the patient’s condition and treatment options.

Levels of MDM:

Straightforward:

 Minimal number of diagnoses or management options.

 Minimal or no data to be reviewed.
 Minimal risk of complications or morbidity/mortality.

Low Complexity:
  Limited number of diagnoses or management options.
 Limited amount and complexity of data to be reviewed.
 Low risk of complications or morbidity/mortality.

Moderate Complexity:

 Multiple diagnoses or management options.

 Moderate amount and complexity of data to be reviewed.
 Moderate risk of complications or morbidity/mortality.

High Complexity:

 Extensive number of diagnoses or management options.

 Extensive amount and complexity of data to be reviewed.
 High risk of complications or morbidity/mortality.

Categories of E/M:
New Office/Outpatient: 99201-99205
Established Office/Outpatient: 99211-99215
Hospital Observation Services: 99217-99220
Subsequent Hospital Observation Services: 99224-99226
Hospital Inpatient Services-Initial Care: 99221-99223
Hospital Inpatient Services-Subsequent Care: 99231-99233
Observation or Inpatient Care Services (Incl. Admit & Discharge): 99234-99236
Care Plan Oversight: 99374-99380
Emergency Department Services (New or Established): 99281-99285
Preventive Medicine: 99381-99397
Critical Care (if criteria not met, code initial or subsequent hospital visit): 99291-99292.
Key Elements of E/M Code Selection
E/M code selection is based on seven elements:
Exam
History
Medical Decision Making (MDM)
Nature of the Presenting Problem
New or Established Patient
Counseling/Coordination of Care
Time
Three Key Elements:
History
Exam
Medical Decision Making (MDM)
Assessment of the Level of Code:
New Patients/ER Visits: All three key elements must be met or exceeded.
Established Patients: Two of the three key elements must be met or exceeded.
Time-Driven Codes:
Counseling/Coordination of Care: If more than 50% of the visit was spent in counseling, the code
selection can be based on time.
Psychiatry
Prolonged Services
Care Plan Oversight
Critical Care
Outpatient Visits: Time is based on face-to-face time spent by the physician with the patient.
Inpatient Visits: Time is based on unit/floor time as well as time spent with the patient.
Basics for Documentation
Legible Entries
Date and Time Entries
Physicians Should:
Read notes before signing.
Document all phone calls.
Document patient education.
Document patient noncompliance with medical protocol.
Initial and date all lab results reviewed.
Use approved abbreviations.
Always support the need for tests or extra services in writing.
Make corrections with a single line through the error (do not use liquid paper or erase the
error).
Addendums: Must be signed and dated if utilized.
Attending and Resident Notes:
Linking Notes: The attending must link their note to the resident’s note for charge review.
Standalone Note: The attending's note will stand alone if not linked to a resident’s note.
Resident Definition: Any person in a GME-approved program, from a PGY 1 to a Fellow.
Components of History
Chief Complaint
History of Present Illness
Review of Systems
Past, Family, and Social History
Components of Exam and MDM
Refer to the 1995 or 1997 Documentation Guidelines for detailed requirements.
E/M Coding Specifics
Concurrent Care: Generally, only one service per day will be reimbursed unless medical necessity
is documented for services provided by different specialties or for different diagnoses.
Medical Student Documentation: Can only be summarized for the history portion if verified by
the attending. The attending must perform and document the exam and medical decision-making
independently.
Steps to Determine E/M Code
Comprehensive History:
Document chief complaint, extended HPI, complete ROS, complete PFSH.
Count HPI elements, body systems reviewed, PFSH areas reviewed.
Comprehensive Examination:
Decide general multi-system or single organ system exam. Follow 1995 or 1997 Documentation
Guidelines. Compare documentation to organ/body system checklists to meet comprehensive exam
requirements.
MDM of High Complexity:
Ensure medical record meets two of three requirements: extensive diagnoses/management
options, extensive data review, high risk of complications.
Apply E/M coding rules, tools, and CMS Documentation Guidelines.
Combine All Three Components:

Each E&M code is determined by the highest levels of two out of the three key components
(history, examination, MDM) for established patients and all three components for new
patients or consultations.

The level of service is based on the most complex component documented.

Match Documentation to Code Requirements:

Ensure that the documented history, examination, and MDM meet the criteria for the
chosen E&M code.

Use the guidelines to verify that all necessary elements are documented properly.

Example 1: Office Visit for an Established Patient (99214):

o History: Detailed HPI (4 or more elements), extended ROS (2-9 systems),

and pertinent PFSH (at least one specific item from two of the three history
areas).
o Examination: Detailed examination of multiple body areas or organ systems
(at least 12 elements or more in the 1997 guidelines).
o MDM: Moderate complexity (multiple diagnoses, moderate data review,
moderate risk).
o Appropriate E&M Code: 99214.

Example 2: Initial Hospital Visit (99223):

o History: Comprehensive HPI (4 or more elements), complete ROS (10 or

more systems), and complete PFSH (at least one specific item from each of
the three history areas).
o Examination: Comprehensive multi-system examination (all elements
identified by bullets in at least 9 organ systems or body areas).
o MDM: High complexity (extensive diagnoses, extensive data review, high
risk).
o Appropriate E&M Code: 99223.

Types of History:
 Problem-Focused:
HPI: Brief (1-3 elements)
ROS: N/A
PFSH: N/A
Expanded Problem-Focused:
HPI: Brief (1-3 elements)
ROS: Problem Pertinent
PFSH: N/A
Detailed:
HPI: Extended (4+ elements)
ROS: Extended
PFSH: Pertinent
Comprehensive:
HPI: Extended (4+ elements)
ROS: Complete
PFSH: Complete

Types of Examination:

The levels of E/M services are based on four types of examinations:

Problem Focused: Limited examination of the affected body area or organ system.
Expanded Problem Focused: Limited examination of the affected body area and
other symptomatic or related systems.
Detailed: Extended examination of the affected body area(s) and related systems.
Comprehensive: General multi-system or complete single organ system examination.
Recognized Body Areas:
Head, including the face.
Neck
Chest, including breasts and axillae.
Abdomen
Genitalia, groin, buttocks
Back, including spine
Each extremity
Recognized Organ Systems:
Constitutional
Eyes
Ears, nose, mouth, and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic
 1995/1997 (E&M) Services Summary

History of Present Illness (HPI):

 1995: Defined an extended HPI as documentation of at least four elements:

o Location (where the patient feels pain or discomfort)
o Duration (how long the symptom has been present)
o Severity (intensity of the symptom)
o Character (quality or description of the symptom)
o Onset (how the symptom began)
o Modifying factors (elements that improve or worsen the symptom)
o Associated symptoms (other symptoms that occur with the main complaint)
 1997: Introduced more flexibility for documenting an extended HPI:
o Option 1: Document at least four elements of the HPI (same as 1995).
o Option 2: Document the status of at least three chronic or inactive conditions.
This could include details about:
 Current status of the condition (stable, worsening, improving)
 Medications used to manage the condition
 Any recent changes or complications related to the condition

Examination:

 1995: Defined the extent of the examination based on documented body areas or organ
systems. 1995 Guidelines:
o General approach.
o Documentation can be based on body areas or organ systems.
o Flexible, narrative style.
o Example: "Chest: Clear to auscultation; Abdomen: Soft, non-tender."
 Body Areas: Seven body areas were listed (e.g., head, neck, chest, abdomen,
extremities). Descriptions lacked specific details about the examination performed.
 Organ Systems: Twelve organ systems were listed (e.g., cardiovascular, respiratory,
gastrointestinal). Documentation focused on whether the system was examined (e.g.,
"lungs clear to auscultation").
 1997: Provided more specific criteria for documenting the examination, with a scoring
system based on the number of organ systems examined. Detailed and structured.
o Specific bullet points for each organ system and body area.
o Checklist style.
o Example: For the respiratory system, document "Inspection of chest and
breathing effort, auscultation of breath sounds, and percussion of the chest."
 Detailed Description: Required a detailed description of the examination findings for
each organ system examined.
 Multiple Systems: Higher E/M levels required examination of multiple organ systems,
with specific details about findings for each system.
 Medical Decision Making (MDM):

Both guidelines require documentation of:

 Number of diagnoses or management options.

 Amount and complexity of data reviewed.
 Risk of complications or morbidity/mortality.

Levels of MDM: Straightforward, Low, Moderate, High.

Choosing Between the Guidelines

1995 Guidelines:

o Preferred for their simplicity and flexibility.

o Suitable for providers who prefer a narrative documentation style.

1997 Guidelines:

o Preferred for detailed and structured documentation.

o Suitable for providers who prefer a checklist approach.

In-Depth Study Guide: Documentation Guidelines for Evaluation and Management

(E&M) Services

Overview

Understanding and applying the 1995 and 1997 Documentation Guidelines for E&M
services ensures accurate and compliant billing. The guidelines emphasize three main
components: history, examination, and medical decision-making (MDM). This guide focuses
on the elements of MDM, including the table of risk, and how to determine the appropriate
E&M code based on the level of MDM, history, and examination.

Key Components of E&M Documentation

Medical Decision Making (MDM)

Elements:

 Number of Diagnoses or Management Options: Consider the

number and types of problems addressed.
 Amount and Complexity of Data to be Reviewed: Consider the
types of diagnostic testing ordered or reviewed.
  Risk of Significant Complications, Morbidity, and/or Mortality:
Consider the risks associated with presenting problems, diagnostic
procedures, and management options.

Table of Risk:

Diagnostic
Level of Presenting Management
Procedure(s)
Risk Problem(s) Options Selected
Ordered
One self-limited or Laboratory tests
Minimal minor problem (e.g., requiring Rest, gargles
cold) venipuncture
Two or more self-
Non-cardiovascular Minor surgery
limited/minor
Low imaging with without risk
problems, one stable
contrast factors, OTC drugs
chronic illness
One or more chronic
illnesses with mild Physiologic tests Prescription drug
exacerbation, under stress, management,
Moderate undiagnosed new diagnostic elective major
problem, acute illness endoscopies without surgery without
with systemic risk factors risk factors
symptoms
One or more chronic Cardiovascular
Emergency major
illnesses with severe imaging with risk
surgery, parenteral
High exacerbation, factors, diagnostic
controlled
acute/chronic illnesses endoscopies with
substances
posing threat to life risk factors
Documentation of an Encounter Dominated by Counseling or Coordination of
Care:

 When counseling and/or coordination of care dominates (more than

50%) the encounter, time is considered the key factor in determining
the level of E&M services.
 Documentation must reflect the total length of the encounter and
describe the counseling and/or activities to coordinate care.

E&M Categories

 Office/Outpatient: Five levels of coding.

 Office and In-Patient Consultations: Five levels of coding.
 Emergency Room Services: Five levels of coding.
 Initial and Subsequent Hospital Visits: Three levels of coding.

Key Components for Code Selection

Extent of History
Extent of Examination
Extent of Medical Decision Making
New or Established Patient
Nature of the Presenting Problem
Counseling or Coordination of Care
Amount of Time Spent with the Patient

 New Patients and Consultations: All three key components must be met or exceeded.
 Established Patients and Subsequent Visits: Two of the three key components must be
met or exceeded.

Code Selection

Select the Proper Level of History, Exam, and Medical Decision Making:

If a row has two or three circles, select the code associated with that row.

If several rows have one circle each, find the row that holds the second circle and select the
code associated with that row.

Determine the Level of HISTORY:

Level Type of History CC HPI ROS PFSH

1&2 Problem Focused Yes 1-3 elements N/A N/A
3 Expanded Problem Focused Yes 1-3 elements 1 N/A
4 Detailed Yes 4 elements 2-9 1 element
5 Comprehensive Yes 4 or more 10+ 2 est. pt., 3 new pt.

Determine the Level of EXAMINATION:

Level Type of Examination Body Systems Examined

1 & 2 Problem Focused One
Expanded Problem Affected area and additional systems (up to
3
Focused seven)
4 Detailed Seven
5 Comprehensive Eight or more systems

Determine the COMPLEXITY of MEDICAL DECISION MAKING:

# of Dx's/Mgt Amt/Complexity of Risk of

Level Decision
Options Data Complications
1 & 2 Straightforward Minimal (1) Minimal or none (1) Minimal (1)
3 Low Complexity Limited (2) Limited (2) Low (2)
 # of Dx's/Mgt Amt/Complexity of Risk of
Level Decision
Options Data Complications
Moderate
4 Multiple (3) Moderate (3) Moderate (3)
Complexity
5 High Complexity Extensive (4+) Extensive (4+) High (4)
Decision Making (2 of 3 required):

A. Number of Diagnoses or Management Options: Clinical impressions, referrals,

changes in treatment.

o Self-limiting/minor problem, stable, improved, worsening (pt.) max = 2

o Established problem, stable, improved well-controlled/resolving or resolved
(1 pt.)
o Established problem, worsening, failing to respond, inadequately controlled
(2 pts.)
o New Problem, no additional workup planned (3 pts.) max = 1
o New problem with additional workup planned (4 pts.) TOTAL =

B. Amount and/or Complexity of Data to be Reviewed: Tests and procedures

ordered, reviewed, and discussed as well as old records reviewed.

o Discuss tests with performing physician (1 pt.)

o Ordered/reviewed labs/x-rays/tests from medicine section of CPT (1 pt.)
o Decision to obtain old records/hx from someone other than the patient (1
pt.)
o Independent review of tracings, specimens or x-rays (2 pts.)
o Review/summarize old records/hx from someone other than the patient (2
pts.) TOTAL =

C. Risk of Complications, Morbidity, and Mortality:

o Based on the risks associated with presenting problems, diagnostic

procedures, and management options.

Practical Application Examples

1. Example 1: Office Visit for an Established Patient (99214):

o History: Detailed HPI (4 or more elements), extended ROS (2-9 systems),
and pertinent PFSH (at least one specific item from two of the three history
areas).
o Examination: Detailed examination of multiple body areas or organ systems
(at least 12 elements or more in the 1997 guidelines).
o MDM: Moderate complexity (multiple diagnoses, moderate data review,
moderate risk).
o Appropriate E&M Code: 99214.
2. Example 2: Initial Hospital Visit (99223):
o History: Comprehensive HPI (4 or more elements), complete ROS (10 or
more systems), and complete PFSH (at least one specific item from each of
the three history areas).
o Examination: Comprehensive multi-system examination (all elements
identified by bullets in at least 9 organ systems or body areas).
o MDM: High complexity (extensive diagnoses, extensive data review, high
risk).
o Appropriate E&M Code: 99223.

Study Guide: Understanding New and Established Patients in E/M Coding

1. New and Established Patients

New Patient

 Definition: A new patient has not received any professional services from the
physician or another physician of the same specialty/subspecialty in the same group
practice within the past three years.
 Three-Year Rule: The previous face-to-face service must have occurred at least
three years before the current date of service.
o Example: A patient seen on Nov. 1, 2014, and returning on Nov. 2, 2017, is
considered a new patient.

Established Patient

 Definition: An established patient has received professional services from the

physician or another physician of the same specialty/subspecialty in the same group
practice within the past three years.

2. Concurrent Care and Transfer of Care

Concurrent Care

 Provision of similar services (e.g., hospital visits) to the same patient by more than
one physician on the same day.
 No special reporting required.

Transfer of Care

 The process where one physician relinquishes responsibility for managing a

patient’s problems to another who agrees to accept the responsibility.
 Consultation codes should not be used if the transfer decision is made before an
initial evaluation.

3. History and Examination

History Components
 Chief Complaint (CC): A brief statement explaining the reason for the encounter.

History of Present Illness (HPI): A chronological description of the development of the

patient's present illness from the first sign/symptom to the present.

o Elements of HPI: Location, Quality, Severity, Timing, Context, Modifying

Factors, Associated Signs and Symptoms, and Duration.

Review of Systems (ROS)

 Purpose: Identify past and present signs and symptoms by asking about body
systems.
 Systems Included: Constitutional symptoms, Eyes, Ears/nose/mouth/throat,
Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal,
Integumentary, Neurological, Psychiatric, Endocrine, Hematologic/lymphatic,
Allergic/immunologic.

Levels of ROS:

o Problem Pertinent: Review of one system related to the problem in the HPI.
o Extended: Review of 2-9 systems.
o Complete: Review of at least 10 systems.

Past, Family, and Social History (PFSH)

 Past History: Previous illnesses, injuries, treatments, current medications, allergies,

and immunization status.
 Family History: Medical events in the patient's family, including hereditary diseases.
 Social History: Past and current activities, employment, drug/alcohol use, education
level, and other relevant social factors.

Components of E/M Services

 E/M services are categorized by seven components, with the first three being key:
1. History: Chief Complaint, History of Present Illness, Review of Systems, Past,
Family, and/or Social History.
2. Examination: Includes body areas and organ systems.
3. Medical Decision Making (MDM): Complexity of establishing diagnoses and
selecting a management option.

4. Medical Decision Making (MDM)

MDM Components

 Number of Diagnoses or Management Options: Clinical impressions, referrals,

changes in treatment.
  Amount and Complexity of Data to be Reviewed: Tests and procedures ordered,
reviewed, and discussed.
 Risk of Complications, Morbidity, and Mortality: Based on the risks associated
with presenting problems, diagnostic procedures, and management options.

Table of Risk

Level of Diagnostic Management Options

Presenting Problem(s)
Risk Procedure(s) Ordered Selected
One self-limited or minor Laboratory tests
Minimal Rest, gargles
problem (e.g., cold) requiring venipuncture
Two or more
Non-cardiovascular Minor surgery without
Low self-limited/minor problems,
imaging with contrast risk factors, OTC drugs
one stable chronic illness
One or more chronic illnesses
Physiologic tests under Prescription drug
with mild exacerbation,
stress, diagnostic management, elective
Moderate undiagnosed new problem,
endoscopies without risk major surgery without
acute illness with systemic
factors risk factors
symptoms
One or more chronic illnesses Cardiovascular imaging
Emergency major
with severe exacerbation, with risk factors,
High surgery, parenteral
acute/chronic illnesses posing diagnostic endoscopies
controlled substances
threat to life with risk factors
5. Determining the Level of Service

Levels of E/M Services

 Problem Focused: Limited examination of the affected body area or organ system.
 Expanded Problem Focused: Limited examination of the affected body area and
other symptomatic or related organ systems.
 Detailed: Extended examination of the affected body area(s) and other
symptomatic or related organ system(s).
 Comprehensive: General multi-system examination or complete examination of a
single organ system.

Code Selection by Level

 Problem Focused: Brief history, focused exam, and straightforward MDM.

 Expanded Problem Focused: Brief history, expanded problem-focused exam, and
straightforward MDM.
 Detailed: Extended history, detailed exam, and moderate complexity MDM.
 Comprehensive: Comprehensive history, comprehensive exam, and high
complexity MDM.

6. Special Scenarios
 On-call or Covering Provider

 Classify the patient as new or established based on the relationship with the
unavailable provider.

APN/PA Working with Physicians

 Consider APNs and PAs as the same specialty and subspecialty as the physician they
are working with.

Multiple Locations

 Consider the patient established if seen by a physician of the same subspecialty in

the same group practice, regardless of location.

Decision Tree for New vs. Established Patient:

Consider the patient new if they have not been seen face-to-face within the past three years by any
provider in the same specialty and subspecialty within the same group practice.
If a provider is on call or covering for another, classify the encounter based on the patient's
relationship with the unavailable provider.
By understanding these guidelines and using them correctly, medical coders can ensure
accurate billing and appropriate reimbursement for services rendered.
Use a decision tree to determine if a patient is new or established based on professional services
received and the time elapsed since the last encounter.

Three-Year Rule:

If a patient has received a face-to-face service from a provider (or another provider in the same
group, specialty, and subspecialty), they are considered established if seen within three years.

Concurrent Care and Transfer of Care:

Concurrent Care: Multiple providers seeing the same patient on the same day for different issues
don't need special reporting.
Transfer of Care: When one provider hands over the management of some/all of a patient's
problems to another provider who agrees to accept it. Consultation codes are used only if the
decision to transfer care happens after an initial consultation.

Documentation Guidelines:

1995 vs. 1997 CMS Guidelines:

1995 Guidelines: Brief HPI includes 1-3 elements; extended HPI includes 4+ elements.
1997 Guidelines: Extended HPI includes 4+ elements or the status of 3+ chronic/inactive
conditions.

Coding and Documentation Guidelines

Follow the CMS 1995 and 1997 Documentation Guidelines for E/M services, which help determine
the type of history, examination, and MDM required for each service level.
Ensure proper documentation for history, ROS, and PFSH to support the chosen E/M code level.
By understanding these components and guidelines, medical coders can accurately code and report
E/M services, ensuring appropriate billing and reimbursement for healthcare providers.

Evaluation and Management (E/M) Modifiers

Overview:
E/M services are included in the global period unless exceptions apply.
Modifiers can be used during the global period if appropriate.
Documentation is crucial to support the use of any modifier.

Surgical Modifiers:

Modifier 22 – Increased Procedural Service: Indicates that the work required to provide a
service is substantially greater than typically required. Must be supported by documentation and
should not be appended to an E/M service.
Modifier 24 – Unrelated E/M by the same physician during a postoperative period: Used for
unrelated E/M services by the same physician during the postoperative period. Not appropriate for
related diagnoses or services.
Modifier 25 – Significant, Separately Identifiable E/M Service by the Same Physician on the
Same Day of the Procedure: Used when an E/M service is above and beyond the usual pre- and
postoperative care associated with the procedure. Documentation must support the necessity of the
E/M service.
Modifier 50 – Bilateral Procedure: Indicates a procedure was performed on both sides of the
body during the same operative session. Correct coding involves one line with modifier 50 using
one unit of service.
Modifier 51 – Multiple Procedures: Used for multiple procedures performed at the same session
by the same provider. Not used on E/M services, Physical Medicine, or Rehabilitation Services.
Modifier 52 – Reduced Services: Used when a service or procedure is partially reduced at the
physician's discretion. Documentation should explain why the service was reduced.
Modifier 53 – Discontinued Procedure: Used when a procedure is terminated due to
extenuating circumstances or those threatening the patient's well-being. Not used for elective
cancellations prior to the induction of anesthesia.
Modifier 57 – Decision for Surgery: Used to indicate that an E/M service resulted in the initial
decision to perform surgery either the day before or the day of a major surgery (90-day global
period).
Modifier FT – Critical Care Only: Used for unrelated E/M visits during a postoperative period or
on the same day as a procedure. Critical care services provided during a global surgical period must
support the definition of critical care.

Global Package Modifiers:

Modifier 24: Unrelated E/M by the same physician during a postoperative period.
Modifier 25: Significant, separately identifiable E/M service by the same physician on the same
day of the procedure.
Modifier 57: Decision for surgery.
Modifier 58: Staged or related procedure or service by the same physician during the
postoperative period.
Modifier 78: Unplanned return to the operating/procedure room by the same physician for a
related procedure during the postoperative period.
Modifier 79: Unrelated procedure or service by the same physician during the postoperative
period.

Key Points:

Modifier 22: Should not be appended to an E/M service.

Modifier 24: Incorrect use includes related diagnoses, treatment of surgery-related infections, or
pain.
Modifier 25: Should not be reported on procedure code 99211 and must reflect significant,
separately identifiable E/M services.
Modifier 50: Used for bilateral procedures, ensuring correct coding practices.
Modifier 51: Applied for multiple procedures performed in the same session.
Modifier 52: Appropriate for intentionally reduced services.
Modifier 53: Used when procedures are discontinued due to patient risk.
Modifier 57: Indicates E/M service leading to the decision for surgery.
Modifier FT: Documentation must support the critical care definition and the unrelated nature of
the service.

Documentation:

Must support the use of each modifier.

For modifiers 52 and 53, documentation should detail the reason for reduced or discontinued
services.
Proper documentation ensures correct reimbursement and compliance.
Understanding these modifiers helps ensure accurate coding and billing, supporting compliance
and optimal reimbursement in medical coding practices.

Overview of Modifiers in Medical Coding

Modifiers are crucial in medical coding as they provide additional information about the performed
service without altering the actual procedure code. They can indicate specific circumstances,
variations, or additional work involved in the service provided. Here's a detailed explanation of
various Evaluation and Management (E/M) and surgical modifiers:

Evaluation and Management (E/M) Modifiers

Modifier 24: Unrelated E/M Service by the Same Physician During a Postoperative
Period
Definition: Used for unrelated evaluation and management services by the same physician during a
postoperative period.
Purpose: Indicates that the E/M service provided during the postoperative period was not related
to the original procedure.
Incorrect Use: When the diagnosis is related to the original surgery, such as treatment for infection
or pain from the surgery.
Modifier 25: Significant, Separately Identifiable E/M Service on the Same Day of the
Procedure
Definition: Indicates a significant, separately identifiable E/M service by the same physician on the
same day of a procedure.
Purpose: Used when the patient's condition requires a significant E/M service beyond what is
typically included in the procedure.
Incorrect Use: Automatically adding to every E/M service, using it for minor issues that do not
require significant additional work, or reporting it on procedure code 99211.
Modifier 57: Decision for Surgery
Definition: Indicates an E/M service resulted in the decision to perform surgery either the day
before or the day of a major surgery (90-day global period).
Purpose: Used when an E/M service leads to the initial decision for surgery.
Global Period Includes:
The day before surgery
The day of surgery
The number of days following surgery
Modifier FT: Critical Care Service Provided During a Global Surgical Period
Definition: Used for unrelated critical care visits during a postoperative period or on the same day
as a procedure or another E/M visit.
Purpose: Reported for critical care visits unrelated to the surgical procedure.
Incorrect Use: When critical care is related to the surgery or not within the global surgery period.

Surgical Modifiers

Modifier 22: Increased Procedural Service

Definition: Indicates that the work required to provide a service is substantially greater than
typically required.
Purpose: Documenting substantial additional work and the reason for it.
Incorrect Use: Appending to an E/M service or using it without substantial documentation.
Modifier 50: Bilateral Procedure
Definition: Indicates a procedure performed bilaterally (on both sides of the body) during the same
operative session.
Purpose: Shows that the procedure was done on both sides.
Incorrect Use: Applying codes for midline organs or different areas on the same side of the body.
Modifier 51: Multiple Procedures
Definition: Used for multiple procedures performed at the same session by the same provider.
Purpose: Indicates that more than one surgical service was performed.
Incorrect Use: Adding E/M services, physical medicine, or rehabilitation services.
Modifier 52: Reduced Services
Definition: Indicates that a service or procedure was partially reduced or eliminated at the
discretion of the physician.
Purpose: When the procedure is not completed in its entirety.
Incorrect Use: Elective cancellation prior to anesthesia or not completing the full procedure
requirements.
Modifier 53: Discontinued Procedure
Definition: Used when a procedure is ended due to extenuating circumstances or those threatening
the patient’s well-being.
Purpose: Indicates the procedure was started but not completed due to risk to the patient.
Incorrect Use: Elective cancellation prior to anesthesia.
Modifier 58: Staged or Related Procedure During Postoperative Period
Definition: Indicates a staged or related procedure by the same physician during the postoperative
period.
Purpose: For procedures planned prospectively at the time of the original procedure.
Example: Follow-up surgeries that are planned as part of the first treatment.
Modifier 78: Unplanned Return to the Operating Room
Definition: Used when an unplanned return to the operating room is needed for a related procedure
during the postoperative period.
Example: A patient undergoing surgery for an incisional hernia related to an earlier gastric bypass
surgery.
Modifier 79: Unrelated Procedure or Service During the Postoperative Period
Definition: Indicates an unrelated procedure or service by the same physician during the
postoperative period.
Example: Performing an unrelated below-the-knee amputation during the postoperative period of a
finger amputation.
Key Points to Remember
Documentation: Must support the use of any modifier, explaining the reason and
circumstances.
Same Physician or Group: For E/M modifiers, "same physician" includes those in the same
group practice and specialty.
Global Period Modifiers: Specifically address the postoperative care and any additional
services provided during this time.
Critical Care Modifiers: FT is for unrelated critical care services, highlighting the need for
highly complex decision-making.