Use of Highest Levels
of E/M Codes
To bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history
must meet the CPT’s definition of a comprehensive history).
The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. In the case of an established patient, it is acceptable for a physician
to review the existing record and update it to reflect only changes in the
patient’s medical, family and social history from the last encounter, but the physician
must review the entire history for it to be considered a comprehensive history.
The comprehensive examination may be a complete single-system exam such as cardiac, respiratory, psychiatric or a complete multi-system examination
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