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, contd 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 complexityDx/tx options Data reviewed Risk Straight-forwardMinimal LowLimited Low ModerateMultipleModerate HighExtensive 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 HistoryExamMDM Face-to- face supervision only Stfrwd5 min PF Stfrwd10 min EPF Low15 min DDModerate25 min CCHigh40 min.

Putting it together:new pts Requires 3 of 3 elements HistoryExamMDM Face-to- face 99201PF Stfrwd10 min EPF Stfrwd20 min DDLow30 min CCModerate45 min CCHigh60 min.

Common errors Undercoding Overcoding

Other settings Same system Different specifics

Health Maintenance AgeNew ptEstablished pt Less than 1 year years years years years years and over

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!