Congress developed E/M standards and recommendations in 1995 and amended them in 1997.
E&M is the abbreviation of evaluation and management codes. E/M coding is the process of converting physician-patient encounters into five-digit CPT codes to enable billing. This coding scheme involves using CPT codes ranging from 99202 to 99499 to reflect services rendered by a physician or other certified healthcare practitioner.
Every billable procedure has a unique CPT code. Most family physician practices rely heavily on E/M codes. By understanding how to correctly document and code for E/M services, family doctors and other qualified health professionals such as nurse practitioners or physician assistants can optimize remuneration and lessen the stress associated with audits.
Services Covered By E&M Coding:
As the name implies, these medical codes apply to visits and services that entail evaluating and monitoring patient health.
For example, Office visits, hospital visits, home services, and preventative medicine services are examples of E/M services.
Services Not Covered By E&M Coding:
Codes for operations and radiologic imaging services are found outside the CPT code set’s E/M.
Important E&M CPT Code Guidelines
The AMA is in charge of developing assessment and management codes and the rules for their use. Physicians and coders must grasp the standards to select the correct E&M codes for the service. The following are vital aspects for better understanding the criteria for choosing the best assessment and management codes.
The AMA yearly CPT manual contains precise documentation rules for each level of service code within the major E&M categories. There are three levels of coding in the E&M types of initial and subsequent hospital visits.
The documentation standards outlined below apply to all medical and surgical services in all contexts. The nature and amount of physical labor and documentation for Evaluation and Management (E/M) services vary depending on the service type, treatment location, and the patient’s status.
When providing E/M services, the broad principles outlined below may be modified to accommodate for these various conditions.
- The medical record should be readable and full.
- Each patient encounter should be documented with the cause for the meeting and pertinent history, physical examination findings, and prior diagnostic test results; evaluation, clinical impression, or diagnosis; plan of care; and date and identification of the observer.
- If the justification for ordering diagnostic and other ancillary services is not documented, it should be obvious.
- The treating and consulting physician should access past and current diagnoses.
- Appropriate level of health risk
- Document the patient’s progress, response to any changes in treatment, and revision of diagnosis.
- Documentation in the medical record should support the CPT and ICD-9-CM codes recorded on the health insurance claim form or billing statement.
Selecting a Code
The seven components of code selection are as follows:
- The scope of History
- The scope of the examination
- The scope of Medical Decision Making
- Making a new or existing patient
- The nature of the presenting issue
- Care coordination or counseling
- Spending time with the patient
The proper evaluation and management of CPT codes are determined by the length of time or total time of the encounter on the date of the meeting. That comprises both face-to-face and non-face-to-face time spent by the physician, as well as the following items:
- Getting ready to see the patient (e.g., review of tests)
- Obtaining and evaluating separately collected historical information.
- Conducting a medically necessary examination and evaluation.
- Counseling patient, family, and caregiver.
- Medications, tests, or procedures must be ordered.
- Referrals and communication with other health care providers (when not separately reported)
- Recording clinical data in an electronic or another health record
- Interpreting data independently and communicating results to the patient/family/caregiver
- Coordination of care (not separately reported).
Separately Reported Services
Any subsequent procedure with a specific procedure code during the same encounter should be reported individually. For example, any diagnostic tests done and billed separately should not be considered when calculating the appropriate evaluation and management CPT codes.
Examination And History
The physician determines the nature and extent of the history and physical examination, which should be medically sound. The nature of the physical examination has no impact on the level of office or other outpatient codes.
If you work in an office, you should take the time to learn about the coding requirements for evaluation and management services. Incorrect or inaccurate billing and coding can result in criminal or civil consequences. Filing false claims intended to get a federal health care payment for no entitlement exists is considered Medicare fraud. So, to complete the requirements of E&M coding services, one should have a complete grip over CPT billing and coding.
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