What are the main E/M coding guidelines used to determine levels?

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What are the main E/M coding guidelines used to determine levels?

E/M levels are determined from how the encounter is documented. There are two pathways: documentation-based criteria (history, examination, and medical decision making) and time-based criteria, used when the time spent on the encounter is the controlling factor. In most cases, you look at the documented history, exam, and MDM to assign a level, and you may also use time-based rules if the visit is predominantly time spent on counseling and care coordination. Time alone isn’t the sole determinant, and diagnosis- or procedure-based guidelines don’t set the E/M level. So the main guidelines are the combination of documentation-based criteria and time-based criteria.

E/M levels are determined from how the encounter is documented. There are two pathways: documentation-based criteria (history, examination, and medical decision making) and time-based criteria, used when the time spent on the encounter is the controlling factor. In most cases, you look at the documented history, exam, and MDM to assign a level, and you may also use time-based rules if the visit is predominantly time spent on counseling and care coordination. Time alone isn’t the sole determinant, and diagnosis- or procedure-based guidelines don’t set the E/M level. So the main guidelines are the combination of documentation-based criteria and time-based criteria.

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