The selection of the code will be determined by the type of service (eg, initial inpatient care, office visit or consultation), the appropriate category of service (ie, new vs established patient), and the performance and documentation of the required key components.

Each family of codes (ie, new patient, consultations, established patient) will have specific requirements for each level of service. For example, the Table outlines the requirements based on the 1995 Centers for Medicare & Medicaid Services guidelines for a new and an established patient office or outpatient visit.

The assignment of the level of service for an evaluation and management code may be easier when using the clinical perspective and these steps. It is critical to document the nature of the presenting problem in the medical record. With thorough documentation of the history (eg, extent of history performed, description of the problems), physical examination (eg, pertinent findings), and assessment...

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