1. Larry Halem, MD, CPC VEP Regional Productivity Director
Understanding E+M
Larry Halem, MD, CPC
VEP Regional Productivity Director

2. Documentation
The majority of physicians do not document properly which leads to the loss of revenue and decreased reimbursement
It’s not more work, it’s doing the work appropriately

3. It’s your money. Stop giving it to the insurance companies

4. Different Levels
There are 5 E+M levels (evaluation and management codes)
Level 1 (99281): 0.6 RVU
Level 2 (99282): 1.17 RVU
Level 3 (99283): 1.75 RVU
Level 4 (99284): 3.32 RVU
Level 5 (99285): 4.9 RVU

5. What determines the E+M level
Determined by components of:
HPI
ROS PE
MDM
Diagnosis

6. History of Present Illness
History: history of present illness
Needs 1-3 components for a level 2 or 3
Needs greater than or equal to 4 components for a level 4 or 5
Different components
Quality
Location
Timing
Duration
Severity
Context
Modifying factors
Associated signs and symptoms

7. Review of Systems ROS: review of systems
Level 3: Need 1
Level 4: Needs 2-9 total
Level 5: Needs 10 total
Documenting pertinent positives and marking all other negative and reviewed in HPI is adequate for a level 5 ROS

8. Past Medical, Family, Social History
PFSH:
Level 4: Needs 1
Level 5: Needs 2
This is a large area that leads to down-coded charts. If you do not place a social or family history this will down-code the entire chart to a level 4

9. Smoking Cessation If they smoke: counsel them
There are 2 categories for billing, but for the ER we will typically only use category: greater than 3 minutes up to 10 minutes
RVU 0.3 RVU

10. Examination PE: physical exam
Level 3 and 4: Needs 2-7 body area/organ systems
Level 5: Needs greater or equal to 8 organ systems

11. Medical Decision Making
Amount and Complexity of Data Reviewed
Level 3: 2 data points
Level 4: 3 data points
Level 5: 4 data points
Data points:
Order lab tests: 1 point
Order radiology tests: 1 point
Order ECG: 1 point
Decision to obtain old medical records and/or history from someone other than patient: 1 point
Review and summarization of old records and/or discussion of case with another health care provider: 2points
Independent visualization and interpretation of radiology study or ECG: 2 points

12. Medical Decision Making
Risk of Complications, Morbidity, and Mortality
This is broken down into the:
Presenting problem
Diagnostic procedures ordered
Management and treatment given

13. Medical Decision Making
Risk of Complications, Morbidity, and Mortality
Level 3:
Acute uncomplicated illness or injury
Minimal diagnostic tests performed
Minor procedures
Oral medications

14. Medical Decision Making
Risk of Complications, Morbidity, and Mortality
Level 4:
Mild exacerbation of chronic problem, acute illness with systemic symptoms, or acute complicated injury
Diagnostic procedures such as labs, radiographic studies including x-ray and CT scans
IV fluids
IM medications for pain

15. Medical Decision Making
Risk of Complications, Morbidity, and Mortality
Level 5
Severe exacerbation of chronic problem or acute or chronic problem posing threat to life or limb
IV narcotic pain medications
IV medications requiring repeated dosing
Diagnostic procedures such as labs with advanced imaging including ultrasound, CT, or MRI
Treatment requiring intense monitoring
DNR or de-escalation of care

16. Medical Decision Making
Formatting an MDM
Backbone of the MDM
Opening is a synopsis of the patient
Body of your MDM is building the differential
Final section is synopsis of the treatment given

17. MDM: RUQ Abdominal Pain
Patient presents with abdominal pain. Labs were performed to evaluate for evidence of electrolyte abnormalities such as hyponatremia, hyperglycemia. Labs including LFT’s and lipase were performed to evaluate for evidence of pancreatitis or hepatitis. Urine shows no evidence of infection. Radiology studies, ultrasound abdomen was performed to evaluate for biliary pathology or cholecystitis and shows no acute intra-abdominal pathology. Patient improved in the ER with IV pain medications, IV antiemetics, and IV hydration.

18. Medical Decision Making
It is the combination of the presenting complaint, diagnostic procedures ordered, and treatment given combined with the reviewed data points that determine the E+M level assigned.
This is the most important section that can be the difference between a level 3, level 4, and level 5