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Evaluation and Management Services

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Evaluation and management (E/M) services are cognitive (as opposed to procedural) services in which a physician or other qualified healthcare professional diagnoses and treats illness or injury. Nearly all physicians provide E/M services, however most services that infectious diseases physicians provide are of the E/M type. Appropriate documentation and coding of E/M services are vital to capturing the medical services provided to infectious diseases patients and therefore are also vital for appropriate reimbursement and compensation. IDSA has curated resources for ID physicians and their staff to assist in a better understand E/M coding. 

Office/Outpatient Evaluation and Management Services Reference Guide and Clinical Examples

This reference guide, prepared specifically for infectious diseases physicians and their staff provides information and real-world clinical examples of how to select the most appropriate CPT code for office/outpatient visit encounters (codes 99202-99215). Definitions of  the various elements of medical decision making and time along with other coding conventions are covered. The clinical examples follow a single patient case, from a minor problem with a low level of medical decision making (MDM) as it then progresses to the highest level of MDM, indicating the elements that led to the code that was chosen.  

Frequently Asked Questions: Office/Outpatient E/M Services

IDSA has prepared an FAQ that answers questions and provides definitions for office/outpatient E/M Services. For other coding questions including CPT, HCPCS and ICD-10 codes, please submit a question via Ask the Coder.

For detailed information on the changes and instructions on how to use the revised E/M codes visit AMA CPT Information Office and Outpatient E/M.

Office and Outpatient E/M Webinar

Developed for infectious diseases physicians and their staff, the Navigating the Revised CPT® Codes for Office and Outpatient E/M Services webinar was created to provide guidance, using real-world clinical examples on how to use the revised office visit E/M CPT® codes. The webinar reviews the changes and provides examples of how to use medical decision making to choose an appropriate CPT® code for a given clinical example. 

CPT copyright 2021 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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