Evaluation & Management Tools

Documentation of medical necessity and billing requirements.

To reduce the complexity and subjectivity of the coding process, the PRS network has developed an E/M coding system to assist the physician and the office staff to more efficiently document and select the correct level of the E/M encounter. The PRS system is based on the the documentation guidelines of CMS.

Easily select the correct level of service for the service provided.

  • Forms ensure proper documentation Wall chart ensures all requirements are met for the correct level of service
  • Pocket card is small and portable

Evaluation & Management Tools


The Wallchart (General Multi-system or Genitourinary) lays out in detail the elements of the three key components necessary for coding an E/M encounter based on CMS guidelines.

  • History Component
  • Physical Exam Component
  • Medical Decision Making Component


The Pocketcard is a reference to help determine the levels of services for each category of service. The Pocketcard, which summarizes the Wallchart, is based on a numerical system as described in the CMS documentation guidelines, as opposed to the more subjective verbal descriptors of CPT.

History Form

The History Form is designed to address the three elements of the history component and the chief compliant. The patient can complete the form, independently, or with the help of a staff member. The physician reviews the form with the patient, makes appropriate notations, signs, and dates the form.

Physical Exam Form

The Physical Exam Form is intended to be a guide for the physician when performing the physical exam to ensure the capture of all the elements/bullets of the physical exam that are performed. Once recorded, it provides a quick reference for determining the level of the exam.

Encounter Review Form

The Encounter Review Form is a worksheet used for recording the elements and subelements obtained from the documentation of an E/M encounter. When learning to code, use the Encounter Review Form as a means of summarizing each of the component levels and select the correct level of E/M code. You will not need to use it as a routine part of coding. Use it to audit charts, as well.

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