Skip to content
English
Back to Outcomes
  • There are no suggestions because the search field is empty.

General Clinical Encounter Workflow

The Clinical Evaluation and Management (E/M) Encounter is a flexible, longitudinal workflow designed to document and manage patient care encounters that rely on clinical judgment, assessment, decision‑making, and care planning rather than discrete procedures or diagnostic tests.

What Is an Evaluation & Management (E/M) Service?

Evaluation and Management (E/M) services refer to the cognitive and decision‑making services provided by healthcare professionals during patient encounters. These services focus on assessing a patient’s health status, formulating or adjusting treatment plans, and coordinating care.

E/M services typically include:

  • Collecting and reviewing patient medical history
  • Conducting a clinical assessment or interview
  • Evaluating symptoms, risk factors, and treatment options
  • Developing, adjusting, or reinforcing a care plan
  • Providing education, counseling, or clinical recommendations
  • Coordinating care or communicating with other providers
  • Providing follow‑up care related to an ongoing condition or plan

Unlike procedures or diagnostic tests, E/M services reflect clinical judgment and personalized care planning that guide patient outcomes.

Common Services That May Use the E/M Workflow

The Clinical Evaluation and Management Encounter may be used to document and support services such as, but not limited to:

  • Chronic Disease Management

    • Hypertension
    • Diabetes
    • Hyperlipidemia
    • Asthma or COPD
    • Ongoing medication therapy management
    • Monitoring disease control and adjusting care plans under protocol

  • Lifestyle Counseling and Preventive Care

    • Lifestyle counseling and goal setting
    • Nutrition, exercise, alcohol, or tobacco counseling
    • Weight monitoring and dietary counseling
    • Preventive care assessments and reinforcement

  • Behavioral Health Support

    • Depression or anxiety screening
    • Medication management for mental health conditions
    • Ongoing monitoring and follow‑up for behavioral health concerns

  • Acute Care Encounters

    • Evaluation and treatment of uncomplicated acute conditions (for example, UTI symptoms, flu‑like symptoms, strep throat evaluations)
    • Assessment, patient education, and care coordination for short‑term conditions

  • Lab Review and Follow‑Up

    • Reviewing laboratory results
    • Monitoring labs and adjusting medications under protocol
    • Communicating normal lab results to patients
    • Reinforcing provider recommendations based on lab findings

  • Care Plan Follow‑Up

    • Following up on previously established care plans
    • Documenting patient‑reported outcomes or progress
    • Adjusting goals or follow‑up plans as appropriate

  • Medication and Clinical Counseling

    • First‑fill counseling
    • Vaccine counseling
    • Medication education and adherence discussions

Billing Considerations

Billing for Evaluation and Management (E/M) services under CPT codes may vary by payer, provider type, and state regulations. Coverage, reimbursement, and documentation requirements are subject to payer policies and may change over time.

It is the responsibility of the provider to:

  • Verify current payer requirements
  • Confirm that services are eligible for billing
  • Ensure documentation supports the level of service billed

Getting Started

Choose a patient

Log into Outcomes, then navigate to the patient profile using one of the following methods:

  • Search for an existing patient in the Outcomes global header.

Or

  • Find the patient in the Clinical Services Upcoming queue under the Patients on the left hand page navigation if you are documenting a follow up encounter.

If the patient is new to your pharmacy, add the patient to your center by clicking the add patient icon in the global header.

Add the patient's medical insurance

  • Once you have selected the patient and you wish to submit the encounter as a medical bill, select the 3 dots to the right of patient's name and select Edit Insurance. Or, on the right side of the page, choose the insurance card icon. This will open an insurance drawer where you can select Add Insurance.
  • Input the required fields for the patient's medical insurance. Please ensure the patient has medical insurance added to their profile and that the information is entered exactly how it appears on the patient's medical insurance card. Once complete, select Save Changes.

If you do not want to submit the encounter as a medical claim, you are not required to enter the patient's medical insurance.

Document an encounter

  • Navigate to the Start a Service section of the patient page using the patient page navigation ribbon on the left side of the patient page.
  • On the Start a Service section, select Clinical Evaluation and Management from the list of available clinical protocol templates.

Encounter Details

  • Select the appropriate visit type and delivery method of the encounter
  • Select the appropriate encounter recipient and date of the encounter 
  • Document the condition(s) being managed in the visit as well as the reason for the visit (optional).
  • Select Next.

Vitals and Labs

  • Input the appropriate vitals and labs for the encounter, documenting the patient's goal as applicable.
  • If you collected the patient's Blood Pressure and/or A1c at your pharmacy, select Collected at Pharmacy as the Source with the applicable date of collection. Note - the appropriate CPTII code for collection of Blood Pressure and/or A1c will be added to the encounter on the backend.
  • Select Next.

Enter any relevant Encounter Notes on the right side of the screen. These Encounter Notes follow the clinical encounter with the patient and are internal only to the pharmacist.

General Assessment

  • Under Preventative Care, document the date of the last visit for each preventative care segment as appropriate.
  • Document your review of the patient's immunization history and assessment for immunization gaps.
  • Under Lifestyle Assessment, document applicable assessment(s) performed during the encounter, including:
    • Exercise
    • Nutrition
    • Alcohol & Tobacco
  • Select Next.

Medication and Condition Assessment

  • Under Medication Assessment, review the patient's reported medications and conditions and select the attestation.
  • Under Drug Therapy Assessment, document your assessment of the patient's adherence to their medication regiment, any gaps in care, and condition assessment.
  • Under Condition Assessment, document your assessment of the patient's condition(s), review of symptoms, and history of present illness as applicable to the encounter. 
  • Under Barriers to Care, document any carriers to care the patient reports, including social determinants of health, and any applicable solutions identified to help address any barrier.
  • Select Next.

At any given time during the encounter, you can select Save for Later if you wish to save your progress on the current encounter and leave it in progress. Note that doing places that encounter under the patient's Pharmacy Opportunities header of the To Do list on the patient with an "In Progress" badge.


Summary & Billing

  • Under Primary Care Provider & Follow-Up, document the patient's primary care provider information as well as any additional notes you wish to include on the Provider Fax Notification.
  • Communicate the encounter via the Provider Fax Notification to the patient's primary care provider.
  • Under Goals and Follow-Up, document any notes for the patient and the date of the patient's follow up visit, if appropriate.
  • Under Encounter Billing, document time spent completing the encounter, appropriate CPT code for the encounter time from the CPT Selection drop down, the primary ICD 10 code from the ICD 10 code drop down, the billing method, and amount collected.
  • Select Next.

Please ensure you have entered all of the patient's medical insurance correctly before selecting the "Submit claim to patient's medical insurance" option.

Visit Summary

  • View the summary of all that you have documented for the encounter, review for accuracy, and add any additional encounter notes. 
  • Select Submit.

CPT Codes Supported in This Workflow

The following CPT codes are supported for documentation and, where applicable, billing through the Clinical Evaluation and Management workflow: 

CPT Code Typical Time Spent  Description
99202 15–29 minutes Office or outpatient visit for the evaluation and management of a new patient, requiring a medically appropriate history and/or examination and straightforward medical decision‑making.
99203 30–44 minutes Office or outpatient visit for the evaluation and management of a new patient, requiring low‑level medical decision‑making or total time within this range.
99204 45–59 minutes Office or outpatient visit for the evaluation and management of a new patient, requiring moderate‑level medical decision‑making or extended total time.
99205 60–74 minutes Office or outpatient visit for the evaluation and management of a new patient, requiring high‑level medical decision‑making or extensive total time.
99211 5–9 minutes Office or outpatient visit for an established patient that may not require the presence of a physician or other qualified health care professional; typically involves minimal clinical decision‑making.
99212 10–19 minutes Office or outpatient visit for the evaluation and management of an established patient, requiring straightforward medical decision‑making or brief total time.
99213 20–29 minutes Office or outpatient visit for the evaluation and management of an established patient, requiring low‑level medical decision‑making or moderate total time.
99214 30–39 minutes Office or outpatient visit for the evaluation and management of an established patient, requiring moderate‑level medical decision‑making or extended total time.
99215 40–54 minutes Office or outpatient visit for the evaluation and management of an established patient, requiring high‑level medical decision‑making or extensive total time.
99401 Approx. 15 minutes Preventive medicine counseling and risk‑factor reduction intervention (for example, lifestyle counseling or health education).
99402 Approx. 30 minutes Preventive medicine counseling and risk‑factor reduction intervention.
99403 Approx. 45 minutes Preventive medicine counseling and risk‑factor reduction intervention.
99404 Approx. 60 minutes Preventive medicine counseling and risk‑factor reduction intervention.

Frequently Asked Questions (FAQs)

  1. What types of services should use the Clinical Evaluation and Management (E/M) workflow? The Clinical Evaluation and Management workflow should be used for patient encounters that involve clinical judgment, assessment, counseling, or care planning, rather than a single discrete procedure or test. Common examples include chronic disease management, lifestyle counseling, behavioral health support, acute care evaluations, lab review and follow‑up, first‑fill counseling, vaccine counseling, and follow‑up on existing care plans.
  2. Do I need to add medical insurance for every E/M encounter? No. Medical insurance information is required only if you plan to submit the encounter as a medical claim. If you are documenting the encounter for clinical purposes only and do not intend to bill medical insurance, adding medical insurance to the patient profile is optional.
  3. Why am I required to complete specific sections in the Medication and Condition Assessment step? To advance past the Medication and Condition Assessment page, you must document:
    1. At least one response under Drug Therapy Assessment, such as:
      1. Medication adherence assessment or
      2. Gaps in therapy AND
    2. At least one response under Condition Assessment, such as:
      • Condition assessment
      • Review of systems
      • History of present illness
  4. What is the difference between Evaluation & Management (E/M) codes and Preventive Medicine Counseling codes? Both code sets support different types of services, and the choice depends on the nature and complexity of the encounter.
    1. Evaluation & Management (E/M) codes (99202–99215) are used when the encounter:
      1. Involves evaluation of a condition or symptoms
      2. Requires medical decision‑making
      3. Includes assessment, diagnosis, or management of clinical conditions
      4. Is selected based on medical decision‑making level or total time
    2. Preventive Medicine Counseling codes (99401–99404) are used when the encounter:
      1. Focuses on counseling, education, or risk‑factor reduction
      2. Does not include diagnosis or management of a medical condition
      3. Is time‑based and preventive in nature (for example, lifestyle counseling or health education)
    3. The code selection depends on what occurred during the visit:
      1. Typically use E/M codes if the encounter includes clinical assessment, evaluation of symptoms, medication or condition management, or clinical decision‑making.
      2. Typically use Preventive Medicine Counseling codes if the encounter is limited to counseling, education, or risk‑factor reduction without clinical evaluation or management.
  5. Can I bill both E/M and Preventive Medicine Counseling for the same visit? Billing rules vary by payer. In many cases, only one primary service type may be billed per encounter. It is the responsibility of the billing entity to verify payer‑specific guidelines and ensure correct billing practices.
  6. Can I save an encounter and return to it later? Yes. You may select Save for Later at any point during the encounter. The encounter will appear under the patient’s Pharmacy Opportunities section with an In Progress status until it is completed and submitted.
  7. Does completing an encounter guarantee reimbursement? No. Completing documentation in the E/M workflow does not guarantee reimbursement. Coverage, reimbursement, and documentation requirements vary by payer, provider type, and state regulations. Pharmacies are responsible for verifying payer policies and submitting compliant claims.
  8. Can I edit an encounter after it has been submitted? Once an encounter is submitted, it becomes part of the patient’s clinical record. If changes are needed after submission, contact Outcomes support.