Making Sense of
Evaluation and Management
Coding

Effective evaluation and management coding, also known as E/M coding, is key to maximizing reimbursement and maintaining proper documentation. Many physicians lose revenue every day because they undercode their services.

By learning the basic E/M coding rules, providers can more accurately code with confidence and ensure that their documentation is in compliance. Electronic Health Records (EHR) software is of great value in facilitating this process but there is no substitute for being well versed with coding rules. This article describes some of the basic components of E/M coding.

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The CPT codes that describe the physician patient encounter are referred to as evaluation and management codes or, more commonly E/M codes. The codes vary depending on the location of the encounter, in the hospital or office, or whether it is an initial or established patient visit. Within each type of visit, there are different levels of care. The fifth digit of the CPT code ends in the numbers 1 through 5, 1 being the lowest level of care and 5 being the highest. For example, the patient's first office visit at "level 2" has an E/M CPT code of 99202. An established patient office visit at "level 4" is coded 99214.

The documentation for evaluation and management coding are based on:

History
Physical Exam
Medical Decision Making

The following is the criteria used to determine which code level to use. The example is an initial patient office visit. The legend of the terms used are as follows:

HPI= History Present Illness
ROI= Review of Systems
PFSH= Past Medical Family Social History



99201

    • Problem(s): self limited or minor

    • Time Spent: 10 minutes

    • Problem focused history: [HPI Brief], [ROS None], [PFSH None]

    • Problem focused examination: 1-5 bullets from 1+ organ systems

    • Straightforward medical decision making:
      • Minimal # of diagnoses/management options
      • Minimal or no amount/complexity of data review
      • Minimal risk of complications/morbidity/mortality

99202
    • Problem(s): low to moderate severity

    • Time Spent: 20 minutes

    • Expanded problem focused history: [HPI Brief], [ROS 1 system], [PFSH None]

    • Expanded problem focused examination: 6 bullets from any organ system

    • Straightforward medical decision making:
      • Minimal # of diagnoses/management options
      • Minimal or no amount/complexity of data review
      • Minimal risk of complications/morbidity/mortality

99203

    • Problem(s): moderate severity

    • Time Spent: 30 minutes

    • Detailed history: [HPI Extended], [ROS 2-9 systems], [PFSH pertinent]

    • Detailed examination: 2 bullets from 6 organ systems OR 12 bullets from 2+ organ systems

    • Medical decision making of low complexity:
      • Limited # of diagnoses/management options
      • Limited amount/complexity of data review
      • Low risk of complications/morbidity/mortality

99204

    • Problem(s): moderate to high severity

    • Time Spent: 45 minutes

    • Comprehensive history - [HPI Extended], ROS 10+ systems], [PFSH Complete]

    • Comprehensive examination - 2 bullets from each of 9 organ systems

    • Medical decision making of moderate complexity
      • Multiple # of diagnoses/management options
      • Moderate amount/complexity of data review
      • Moderate risk of complications/morbidity/mortality


99205

    • Problem(s): moderate to high severity

    • Time Spent: 60 minutes

    • Comprehensive history: [HPI Extended], [ROS 10+ systems], [PFSH Complete]

    • Comprehensive examination: 2 bullets from each of 9 organ systems

    • Medical decision making of high complexity:
      • Extensive # of diagnoses/management options
      • Extensive amount/complexity of data review
      • High risk of complications/morbidity/mortality

This information should give you a start. For more help on proper documentation and E/M coding, contact Arliene below.

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