Evaluation and Management Codes

Justine Strand, MPH, PA-C

Patricia Castillo, MS, PA-C

Victoria Kaprielian, MD

Basics of E&M coding

• history

• physical examination

• medical decision making

• time

Categories of E&M codes

• Outpatient

• Inpatient

• Consultation

• Emergency department

Categories of E&M codes, cont’d

• Nursing home

• Rest home

• Home visits

• Other

Levels of codes

• Problem focused

• Expanded problem focused

• Detailed

• Comprehensive

History levels

• Problem focused (PF)– chief complaint– brief HPI

• Expanded problem focused (EPF)– CC, HPI– problem-pertinent ROS

History, continued

• Detailed (D)– CC, HPI– extended ROS– pertinent PMH, FH, or SH

• Comprehensive (C)– CC, HPI– complete ROS, PMH, FH, SH

History examples: asthma

• PF: Breathing fine, no complaints

• EPF: include medication use, recent URI sx

• D: add assessment of exposure to allergens, family hx asthma, some ROS

• C: lifelong history of asthma; full PMH, FH, SH, ROS

Exam levels

• Problem focused (PF)– affected body area or organ system

• asthma example: lungs

Exam levels, continued

• expanded problem focused (EPF)– above plus– other symptomatic or related organ systems

• example: lung exam plus ENT or heart

Exam, continued

• Detailed (D)– extended exam of affected body area and

related organ systems

• exam of lungs, ENT, cardiovascular, and extremities

Exam, continued

• Comprehensive (C)– complete multi-system exam

• complete exam

Basics of E&M coding

• history

• physical examination

• medical decision making

• time

Elements of medical decision-making

• number of diagnoses and management options to be considered

• amount and complexity of data reviewed– labs– prior records– consultant reports

• risk level: complications, morbidity, mortality

Diagnoses and decision-making

• Beware of “coding by diagnosis”

Medical decision-making

Level complexity Dx/tx options Data reviewed

Risk

Straight-forward Minimal Minimal Minimal

Low Limited Limited Low

Moderate Multiple Moderate Moderate

High Extensive Extensive High

Decision-making examples

1. doing fine, no change

2. check peak flow, adjust medications

3. nebulizer treatment with peak flows before and after, review past levels, add steroid, discuss criteria for urgent care

4. start home nebs, oral steroids; review hospital chart; discuss medication side effects and risks; consider hospitalization, discuss criteria for ER

Other factors

• New vs. established patient– new = not seen within 3 years– documentation requirements stricter (3/3)

Other factors

• time– lesser element– use if counseling > 50% of encounter– document face-to-face time

Putting it together: established pts

• Requires 2 of 3 elements

History Exam MDMFace-to-

face

99211supervision

onlysupervision

onlyStfrwd 5 min.

99212 PF PF Stfrwd 10 min.

99213 EPF EPF Low 15 min.

99214 D D Moderate 25 min.

99215 C C High 40 min.

Putting it together: new pts

• Requires 3 of 3 elements

History Exam MDMFace-to-

face

99201 PF PF Stfrwd 10 min.

99202 EPF EPF Stfrwd 20 min.

99203 D D Low 30 min.

99204 C C Moderate 45 min.

99205 C C High 60 min.

Common errors

• Undercoding

• Overcoding

Other settings

• Same system

• Different specifics

Health Maintenance

Age New pt Established pt

Less than 1 year 99381 99391

1-4 years 99382 99392

5-11 years 99383 99393

12-17 years 99384 99394

18-39 years 99385 99395

40-64 years 99386 99396

65 and over 99387 99397

Procedures

• Procedure only visits

• Combined procedure and E&M visits

• Modifier -25

Modifier 25

• Health maintenance visits

• Reimbursement issues

Prolonged services

• Face-to-face

• Other

Prolonged services

• Examples

How it works in practice

• Each practice develops their own system

• Encounter forms--provider marks with:– charge code(s)– diagnoses– procedures/tests/therapies performed

What if you get it wrong?

• undercoding

• overcoding

Summary

• Code for what you do

• Document in sufficient detail to justify level

• Be as specific as possible

• Include diagnoses appropriate for every service delivered

• Remember modifiers when needed

• Keep learning!