in 1992 by the American Medical Association (AMA), E/M codes are used by every type of physician to report patients' encounters for health-related problems. They are considered the cognitive codes because physicians must gather and analyze data and information regarding each patient to make a decision about the condition and determine how to manage it. Because they are used so often and so widely, the E/M codes and section guidelines are listed first in CPT.
The first three of these components (history, examination, and medical decision making, abbreviated H/E/MDM are
For established patients, two of the three key components must be considered.
The level of service is indicated in each of the code descriptions in the CPT E/M section.
That said, we cannot audit and educate E/M coding without knowing E/M coding.