Evaluation and management (E/M) services make up the majority of services reported by physicians. Yet physicians continue to experience apprehension when selecting the level of service that was performed and documented. Many resort to consistently reporting the same level of service for each set of codes (eg, office visits, hospital care), believing this to be a safe alternative.

Multiple factors contribute to the difficulty in selecting the level of E/M service.

Therefore, this issue of AAP Pediatric Coding Newsletter™ is dedicated solely to coding for E/M services when using the required key components. (Please refer to the April 2009 issue [Vol 4, No. 7], found at http://coding.aap.org, for a detailed explanation of reporting E/M services based on time.) The intent of this issue is to clarify E/M coding guidelines and documentation requirements, thereby simplifying the code selection process.

The majority of E/M services require the performance and documentation of...

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