Name of Manual - Blue Cross and Blue Shield of Minnesota

Evaluation and
Management (E/M)
Coding Policies and Guidelines (Medical Services)
Evaluation and management (E/M) services refer to visits and
consultations furnished by physicians or other qualified
practitioners.
The E/M section of the CPT manual is divided into broad
categories such as office visits, hospital visits, and consultations.
Each section has basic guides or requirements for selection, such
as new versus established patient, or office versus hospital based
services.
Evaluation and Management Basics
Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue
Cross) would like to clarify and expand on our requirements for
E/M services. The following guides cover how Blue Cross treats
preventive and illness E/M services and what Blue Cross expects
for documentation if the claim is appealed.
Documentation
Blue Cross requires reasonable documentation that services are
consistent with the health plan coverage provided, that services are
medically necessary, and appropriate diagnostic and/or therapeutic
services are provided and/or the services furnished have been
accurately reported. Documentation does not need to be submitted
with every claim; however, it must be readily available on request
or submitted, as appropriate, with an appeal or replacement claim.
It is important to note that even if all requirements of a code are
documented, if medical necessity is not established, the service
may be denied.
The principles of documentation listed below are applicable to all
types of medical and surgical services in all settings. For E/M
services, the nature and amount of physician work and
documentation varies by type of service, place of service and the
patient's status. The general principles listed below may be
modified to account for these variable circumstances in providing
E/M services.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
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