1. Evaluation and management (E/M) Services
By Alex Munoz, CPC, NCICS

2. Objectives Identify and explain the 3 factors of E/M code assignment
Differentiate between a new and established patient
Differentiate between an inpatient and an outpatient
Explain the levels of E/M service

3. “If it isn’t documented, it didn’t happen.”
Coding for Services
Your job is to code what is documented within medical record
“If it isn’t documented, it didn’t happen.”

4. Evaluation & Management
Services performed by a doctor/medical provider:
Critical Care, Neonatal Critical Care
Office visits
Hospital visits
Emergency Department
Home Visits, SNF Visits
Preventive Services

5. Three Factors of E/M Codes
Place of service
Type of service
Patient status

6. Place of Service Explains setting of service: Office
Emergency Department
Nursing Home, etc.

7. Type of Service Physicians provide many types of services:
Office visits
Hospital visits
Consultations (not for Medicare)
Critical Care

8. Patient Status Four status types: New patient Established patient
Outpatient
Inpatient

9. New Patient
Has not received any face-to-face service in last 3 years from:
The same physician
From another physician of the same specialty and in same group
New patients more labor intensive for physician and staff

10. Established Patient
Has received face-to-face services in last 3 years from:
The same physician or
Another physician of same specialty in same group
Medical record available with current, relevant information

11. Outpatient
One who has not been formally admitted to a health care facility
Example: Patient receives service at clinic or same-day surgery center
Example: Patient admitted to “observation” status

12. Inpatient
One who has been formally admitted to a health care facility (e.g., hospital, nursing facility, etc.)
Attending physician dictates:
Admission orders
H & P
Requests consultations

13. Levels of E/M Service Based On…
Nature of the presenting problem (foundation)
Skill required to provide service
Time spent (if 50% of total time is counseling or coordination of care)
Level of knowledge necessary to treat patient (MD, PA, RN)
Effort required/assumed
Responsibility required

14. E/M Levels Are Divided Based On
Key Components (KC)
Contributory Factors (CF)
Every encounter contains varying amount of KC and CF

15. 3 Key Components
History (Problem focused, Expanded problem focused, Detailed, or Comprehensive)
Examination (Problem focused, Expanded problem focused, Detailed, or Comprehensive)
Medical decision making (Straightforward, Low complexity, moderate complexity, or high complexity)

16. Contributory Factors Counseling Coordination of care
Nature of presenting problem
Time

17. Now let’s practice…….

18. References:
Buck, C. (2010). Step by Step. Elsevier.