Evaluation and Management (E/M) Coding Flashcards Part 1

Flashcards for Evaluation and Management (E/M) Coding Review

Evaluation and Management (E/M) Services

A specific set of CPT codes used to report professional services, and in some cases, facility services.

New Patient (Outpatient Setting)

A patient who has not received any face-to-face professional services from the physician (or a physician of the same specialty/subspecialty in the same group practice) within the past three years.

Established Patient (Outpatient Setting)

A patient who has received professional services from the physician (or a physician of the same specialty/subspecialty in the same group practice) within the past three years.

Professional Services

Face-to-face services provided by physicians and other qualified health care professionals who may report evaluation and management services.

Medical Decision Making (MDM)

One of two options (along with time) for selecting an E/M level of service.

Problems Addressed

A disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter; with or without a diagnosis being established at the time of the encounter.

Acute Uncomplicated Illness or Injury (Low MDM)

Examples include cystitis, allergic rhinitis, or a simple sprain.

Acute Illness with Systemic Symptoms (Moderate MDM)

Examples may include pyelonephritis, pneumonitis, or colitis.

Stable Chronic Illness

An example could be well-controlled hypertension, a cataract, or BPH. Falls under both low and moderate MDM.

Prolonged Services Code 99417

Reported for each additional 15 minutes spent above the required time threshold for the outpatient service code.

Prolonged Services Code 99418

Reported for each additional 15 minutes spent above the required time threshold for the inpatient and observation service code.

Shared Service

A service where payment is allowed to a physician or a non-physician provider (NPP) for a split or shared visit when both providers are part of the same group.

Substantive Portion (Shared Service)

Defined as more than half of the total time spent, or a substantive part of the medical decision making.

Medical Necessity

E/M services must be reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of a malformed body member.