Using the tables to determine E/M codes

Step 1 Determine whether a visit should be coded as a New Patient, Consultation, or an Established Patient as defined in table 1 or 2. The tables are divided into columns corresponding to the level of E/M service and E/M code. The level of service of the visit and level of code is determined by the number of bullets/elements recorded in the note for each of the Key Components. Step 2: Review the History key component. Every note needs a Chief Complaint.