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

Course Overview

  • The course has been updated for the current calendar year, with updated pages marked by an asterisk.
  • The course aims to teach what constitutes an Evaluation and Management (E/M) service and how to select the appropriate CPT code.
  • It covers the structure of E/M codes, how to determine levels of service based on medical decision making (MDM) or time, and key definitions.
  • The course includes three lessons and an assessment.
    • Lesson 1: Basic structure of E/M codes.
    • Lesson 2: Deep dive into medical decision making.
    • Lesson 3: Time-based billing, including prolonged services.

Lesson 1: Basic Structure of E/M Codes

  • Covers the different categories of E/M services and E/M guidelines.
  • Objectives:
    • Identify code categories and subcategories.
    • Define new vs. established patients and initial vs. subsequent encounters.
    • Name the two options for selecting an E/M level of service.
  • E/M services are CPT codes used to report professional services (and sometimes facility services).
  • The course focuses on professional services, specifically visits between a patient and a physician or healthcare provider.
  • Classification is based on type of service, place of service, and patient status.
  • The format to classify the levels of the E/M service is generally the same across categories.

Definitions

New Patient (Outpatient Setting)

  • One who has not received face-to-face professional services from the physician or qualified health care professional.
    • Or another physician/qualified health care professional of the exact same specialty/subspecialty.
    • Who belongs to the same group practice within the past three years.

Established Patient (Outpatient Setting)

  • One who has received professional services from the physician or qualified health care professional.
    • Or another physician/qualified health care professional of the exact same specialty/subspecialty.
    • Who belongs to 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 E/M services.

Note

  • If a provider is covering for another, classify per the unavailable physician's/qualified health care professional's relationship to the patient.

  • After determining the category and subcategory, a level of service must be determined, supported by MDM or time.
    For outpatient services

  • New patients: codes 99202-99205 correspond to levels 2-5.

  • Established patients: codes 99212-99215 correspond to levels 2-5.

For inpatient/observation services

  • Initial visits: codes 99221-99223.
  • Subsequent encounters: codes 99231-99233.

Lesson 2: Medical Decision Making (MDM)

  • Covers the criteria for code selection for E/M services using MDM elements.
  • Objectives:
    • Categorize problems as low, moderate, or high complexity.
    • Apply the data criteria as defined in the guidelines.
    • Identify and select the level of risk of patient management.
    • Choose a level of service based on MDM.
  • History and exam are essential but are not components used in the code selection.
  • Code selection is determined by either the documented MDM or time.

Elements of MDM:

  • Number and complexity of problems addressed (Element A).
  • Amount and/or complexity of data to be reviewed and analyzed (Element B).
  • Risk of complications and/or morbidity or mortality (Element C).

To meet a level of MDM, two of the three elements must be met.

Element A: Problems Addressed

  • A problem is defined broadly as any disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, regardless of whether a diagnosis is established at the time.

  • MDM Levels:

    • Low: Acute uncomplicated illness/injury (e.g., cystitis, allergic rhinitis, simple sprain).

    • Moderate: Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis).

      • Stable chronic illness is listed under both low and moderate. Examples: well-controlled hypertension, cataract, or BPH.
      • Two or more stable chronic illnesses meet criteria for moderate MDM.
      • Undiagnosed new problem with uncertain prognosis is included at moderate level. An example may be a lump in the breast.

      Definitions for terms used to describe problem complexity levels are crucial for correct identification.

Element B: Data

  • Three categories of data:
    • Tests, documents, or independent historian(s).
    • Discussion of management or test interpretation.
    • Independent interpretation of tests.
  • MDM Levels:
    • Low: One category required (e.g., one lab test and one X-ray ordered).
    • Moderate: One category, e.g., moderate level, ordering three separate lab tests
    • High: Two of the three categories met (e.g., ordering three lab tests and discussing results with a radiologist).

Element C: Risk

  • Risk of patient management complications, morbidity, and or mortality. The risk related to further diagnostic testing or treatment for the patient.
  • Level of risk is based on the appropriate treatment of the problem(s) addressed during the encounter
  • Includes medical decision making by the physician related to the need to initiate or forego further testing, treatment, and/or hospitalization during the encounter.

Specific examples are present in the moderate and high categories.

  • Example of high risk: drug requiring intensive monitoring for toxicity.

    • Monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect. However, if severe hypoglycemia was a current significant concern, then this would be classed as intensive monitoring for toxicity.
    • Annual electrolytes and renal function for a patient on a diuretic, as the frequency does not meet the long term threshold of less than quarterly.
      To meet an MDM level, two of the three elements must meet the criteria for that level.

MDM Level determination:

  • Example 1:
    • Element A: Moderate
    • Element B: High
    • Element C: Moderate
    • Overall: Moderate visit.
  • Example 2:
    • Element A: Low level (stable chronic illness)
    • Element B: None
    • Element C: Low risk
    • Overall: Low level MDM.

Lesson 3: Time-Based Billing

  • Covers criteria for code selection based on total time and how to pick a level of service based on total time.
  • Objectives:
    • Know when applying a prolonged services code in addition to the e/m code is appropriate.
  • For E/M services, time can be used whether or not counseling and/or coordination of care dominates the service.
  • Time includes provider face-to-face and non-face-to-face time.
  • Time cannot be used to select the level of an emergency department E/M service.

Time-Based Billing Considerations:

  • Only distinct time should be summed for shared or split visits.
  • When two or more billable providers jointly meet with or discuss the patient, only the time of one individual should be counted.
  • Documentation should indicate the total time spent on the day of the visit.

Prolonged Services

  • Codes 99417 or 99418 are add-on codes used with the highest level E/M codes.

  • The primary service must be supported by total time and not MDM.

    *Report code 99417 for each additional fifteen minutes spent above the required time threshold for the outpatient service code and 99418 for each additional fifteen minutes spent above the required threshold time for the inpatient and observation service code.
    *Two Different Codes*

  • 99417: Outpatient E/Ms.

  • 99418: Inpatient/Observation E/Ms.

Example

  • Established office visit: provider documents 71 minutes.
  • Primary E/M service based on time: 99215 (met/exceeded 40-minute threshold).
  • Remaining time: 31 minutes = two units of 99417.
  • Coded as: 99215 and 99417 x 2.
    The primary E/M service code must be based on time and the highest level available in that category. example, you may not report 99,417 with 99214.

CMS Prolonged Service Codes

  • Medicare (CMS) has different codes for prolonged services with different time thresholds.

  • Same basic rules apply: prolonged service codes can only be reported when the highest level of service has been selected based on time.

  • Additional time spent cannot be less than 15 minutes.

  • CMS Time Ranges: example, nine nine two one five time span is forty to fifty four minutes. We cannot report a prolonged service code until fifteen minutes past fifty four.
    Example

  • Revisiting the established patient visit (71 minutes total).

  • Primary E/M service based on time: 99215.

  • Adding the additional fifteen minutes to fifty four gives us 69.

  • One unit of G2212 can be reported (99215 + G2212).

Shared Services

  • A shared service allows payment to a physician or a non-physician provider (NPP) for a split or shared visit.
  • Both the physician and NPP are part of the same group.
  • The billing provider personally performs a substantive portion of the visit.
  • The substantive portion is defined as more than half of the total time spent or a substantive part of the medical decision making.

Medical Necessity

  • All E&M services must support that they are reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of a malformed body member.