Department of Neurology

EVALUATION AND MANAGEMENT (E/M)

CODING AND DOCUMENTATION

FOR OUTPATIENT NEUROLOGY:

Levels 1 and 2

By its inherent nature, levels 1 and 2 are seldom used for neurology outpatient evaluation E/M services. They are appropriate to use when the medical decision making is straightforward. There are two codes of each category, depending on whether the history or exam are problem focused or expanded problem focused. For the specifics of these codes, see the table below.

Alternative E/M Coding: Using Time

If you document the total time and note that counseling and coordinating care required more than 50% of the encounter, then time may be used to determine the level of service. Documentation may refer to:

•  prognosis

•  differential diagnosis

•  risks, benefits of treatment

•  instructions

•  compliance

•  risk reduction

The average total times (face-to-face with the patient and/or family) for the common E/M outpatient codes and average Medicare reimbursement are listed below.