The role of evaluation and management services in pain management

Evaluation and management services are an integral part of interventional pain management. Health Care Financing Administration "HCFA" and American Medical Association "AMA" promulgate rules and regulations in the evaluation and management arena. Proper understanding and appropriate coding is a crucial part of interventional pain management, as consequences of inappropriate coding and insufficient documentation to support charges billed to Medicare include not only civil monetary penalties, but exclusion from Medicare program and prison terms. Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including the past and present illnesses, examinations, tests, treatments, and outcomes. In essence, proper medical record documentation must provide the information and answer the questions including why?, what?, where?, and when?. Descriptors for the levels of evaluation and management services recognize seven components which include history, physical examination, medical decision making, counseling, coordination or care, nature of the presenting problem, and time spent. Based on the type of history, physical examination, complexity of medical decision making, patient evaluation services are of several types, which include problem focused, expanded problem focused, detailed, comprehensive with moderate complexity, and comprehensive with high complexity. History includes chief complaint; history of present illness; review of systems; and past, family, and/or social history. Similar to the history, physical examination also encompasses four types, which include a problem focused examination, an expanded-problem focused examination, a detailed examination, and a comprehensive examination. This review describes evaluation and management services of new patients, as well as established patients with sample office evaluations.