History and exam for E/M services

“E/M Codes that have levels of services include a medically appropriate history and/or physical examination when performed. The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified healthcare professional reporting the service. The care team may collect information and the patient or caregiver may supply information directly (e.g., by electronic health record portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in the selection of the E/M services.” CPT 2025 Professional Edition, AMA P. 7

Key Points:

• History and exam are important in a clinical note, but they are not used in determining the level of service.
• The term “when performed” in a CPT® code indicates that it is not a required component, and no additional reimbursement is associated when it is performed.
• A medically appropriate history and exam are critical in understanding the MDM in notes.

Where has medical necessity gone? Nowhere. CMS continues to say that medical necessity is the overarching criterion in determining the level of service. Medical necessity and medical decision-making are not synonymous.