E&M INTRODUCTION
E&M INTRODUCTION
• Evaluation and management (E/M) services
are at the core of most family medicine
practices and represent a category of Current
Procedural Terminology (CPT) codes used for
billing purposes.
E&M INTRODUCTION
• Evaluation and Management coding is a
medical coding process in support of medical
billing. Practicing health care providers in the
United States must use E/M coding to be
reimbursed by Medicare, Medicaid programs,
or private insurance for patient encounters.
E&M IN HEALTHCARE
• E&M codes are used to represent the various
physician and provider services primarily centered
around the evaluation and management of patients.
• E&M coding is not about procedures or tests but
rather focuses on the cognitive services provided by
healthcare professionals, such as patient
consultations, physical examinations, and medical
decision-making processes.
E&M SERVICES CODE
• Evaluation and management codes system
that involve the use of CPT codes from the
range 99202 to 99499 which represent
services provided by a physician or other
qualified healthcare professional.
E&M SERVICES CODE
• These E&M CPT codes are commonly used by
specialty care consultants, emergency room
physicians and primary care physicians. For example,
office visits, hospital visits, home services and
preventive medicine services are considered E&M
codes.
• Codes for procedures like surgeries, radiology and
diagnostic tests, and certain treatment therapies are
not considered evaluation and management services.
SIGNIFICANCE OF E&M
The Significance of E&M Coding in Healthcare
• The utilization of E&M codes or is a fundamental
aspect of medical billing.
• These codes determine the reimbursement level for
the time and effort spent by healthcare professionals
in assessing and managing a patient's care.
• Inaccurate or inappropriate E&M medical abbreviation
coding can lead to either underbilling , which means a
loss of revenue for the healthcare provider, or
overbilling, which can result in audits, fines, and even
legal action.
E&M CODING GUIDELINES
• To ensure accuracy and compliance, the Centers for
Medicare & Medicaid Services (CMS) and the AMA
have established detailed E&M coding guidelines.
• These guidelines provide a framework for selecting
the correct E&M code based on various factors such
as the complexity of the medical decision-making,
the intensity of the evaluation, and the setting in
which the service is provided (such as a hospital,
outpatient clinic, or private office).
E&M COMPLEXITY AND
SETTING
• The evaluation and management guidelines
categorize E&M services based on the complexity of
patient care. The codes are divided into levels that
reflect the intensity of medical decision-making –
from straightforward to highly complex cases.
E&M CODING GUIDELINES
Documentation
• Proper documentation is the cornerstone of E&M
coding. The EM coding guidelines emphasize the
importance of detailed and accurate medical records.
• Physicians and healthcare providers must document
the patient's history, examination findings, and
decision-making processes in a manner that justifies
the E&M code selected. This documentation not only
supports billing but also ensures continuity of care.
E&M SERVICES
Breadth and Scope
• E&M services encompass a wide range of patient
interactions. These services include, but are not
limited to, routine office visits for chronic conditions,
hospital follow-ups, emergency department visits,
and complex consultations for new or acute
problems.
• Each type of interaction has specific coding
requirements that reflect the service's complexity
and the provider's effort.
E&M CODES
The Building Blocks of Medical Billing
• E/M codes are the building blocks of medical billing
in outpatient and hospital settings.
• They are the most frequently used codes and
significantly impact healthcare providers' revenue
cycle management.
• Accurate E/M coding ensures that providers are fairly
compensated for the time and complexity involved in
patient care.
COMMONLY USED TERMS
• New patient - A new patient is one who has not
received any professional services from the
physician/qualified health care professional or
another physician/qualified health care professional
of the exact same specialty and subspecialty who
belongs to the same group practice, within the past
three years.
• Established patient - An established patient is one
who has received professional services from a
physician or a physician in the same group practice of
the same specialty within the previous 3 years.
COMMONLY USED TERMS
• Chief complaint - The chief complaint is obtained by
the Physician in the initial part of the visit when the
medical history is being taken . It will be elicited by
asking the patient what Symptom, problem,
condition, or other factor that is reason for the
encounter.
• Counseling – Discussion with the patient and/or
patient’s family regarding test result, prognosis,
treatment, compliance and education.
COMMONLY USED TERMS
• Presenting problem - disease , condition, injury,
illness, complaint or other reason for encounter.
• System review – A review of systems (ROS), also
called a systems enquiry or systems review, is a
technique used by healthcare providers for eliciting a
medical history from a patient.
• Time - it is refers to the time spent with the patient
by provider.
E&M CODES
E&M codes are organized into the following subcategories:
• (99201–99215) Office/other outpatient services
(99217–99220) Hospital observation services
(99221–99239) Hospital Inpatient services
(99241–99255) Consultations
(99281–99288) Emergency department services
(99291–99292) Critical care services
(99304–99318) Nursing facility services
(99324–99337) Domiciliary, rest home (boarding home) or
custodial care services
(99339–99340) Domiciliary, rest home (assisted living), or home
care plan oversight services
E&M CODES
• (99341–99350) Home health services
(99354–99360) Prolonged services
(99363–99368) Case management services
(99374–99380) Care plan oversight services
(99381–99429) Preventive medicine services
(99441–99444) Non face-to-face office visits
(99450–99456) Special evaluation and management services
(99460–99465) Newborn care services
(99466–99480) Inpatient neonatal intensive, and
pediatric/neonatal critical care services
(99487–99489) Complex chronic care coordination services
(99495–99496) Transitional care management services
(99499) Other evaluation and management services
E&M CODES
• The descriptors for the levels of E/M services
recognize three components which are used in
defining the levels of E/M services. These
components are:
1. History;
2. Examination;
3. Medical decision making
E&M CODES
• Select the appropriate level of E/M services
based on the following:
1. The level of the MDM as defined for each
service or
2. The total time for E/M services performed
on the date of the encounter.
E&M CODES
• MDM has been composed of the following
three components:
1. Diagnosis
2. Patient Data reviewed
3. Treatment Options
E&M CODES
• There are four levels of MDM:
1. Straight forward
2. Low
3. Moderate
4. High
E&M CODES
• OFFICE VISIT - New Patient
99202 - SF- 15-29 minutes
99203 - Low - 30-44 minutes
99204 - Moderate -45- 59 minutes
99205 - High - 60 - 74 minutes
E&M CODES
• OFFICE VISIT - Established Patient
99212 - SF- 10-19 minutes
99213 - Low - 20-29 minutes
99214 - Moderate -30-39 minutes
99215 - High - 40 - 54 minutes
E&M CODES
• INPATIENT VISIT OR OPD VISIT - Admit
Day/Initial Day
99221 - SF/Low - 40 minutes
99222 - Moderate -55 minutes
99223 - High - 75 minutes
E&M CODES
• INPATIENT VISIT OR OPD VISIT - Subsequent
Day
99231 - SF/Low - 25 minutes
99232 - Moderate - 35 minutes
99233 - High - 50 minutes
E&M CODES
• INPATIENT VISIT OR OPD VISIT - Discharge
Day
99238 - 30 minutes
99239 - more than 30 minutes
E&M CODES
• ER VISIT OR ED VISIT
99282 - SF
99283 - Low
99284 – Moderate
99285 - High
E&M CODES
• NF - Admit day/Initial day
99304 - SF/Low - 25 minutes
99305 - Moderate -35 minutes
99306 - High - 45 minutes
E&M CODES
• NF - Subsequent Day
99307 - SF - 10 minutes
99308 - Low -15 minutes
99309 - Medium - 30minutes
99310 - High - 45 minutes
E&M CODES
• NF - Discharge Day
99315 - 30 minutes
99316 - more than 30 minutes
E&M CODES
• HOME/GROUP HOME/ALF - New Patient
99341 - SF- 15 minutes
99342 - Low - 30 minutes
99344 - Moderate - 60 minutes
99345 - High - 75 minutes
E&M CODES
• HOME/GROUP HOME/ALF VISIT - Established
Patient
99347 - SF- 20 minutes
99348 - Low - 30 minutes
99349 - Moderate - 40 minutes
99350 - High - 60 minutes
E&M CODES
E/M Additional Time Codes
Non- Medicare Medicare
Office Visit - 99417 Office Visit - G2212
Hospital - 99418 Office Visit - G3016
NF - 99418 Office Visit - G3017
Home/GH/ALF - 99418 Office Visit - G3018
E&M CODES
• PLACE OF SERVICE
02 – Telehealth
11 – Office
12 – Home
13 – ALF
14 - Group Home
E&M CODES
• HOSPITAL
19 - Off- Campus OPD
22 - On- Campus OPD
21 - Inpatient
23 – ER
• NURSING FACILITY
31 – SNF
32 – NF
34 – Hospice
20 - Urgent Care
E&M CODES
• NURSING FACILITY
31 – SNF
32 – NF
34 – Hospice
20 - Urgent Care
24 – ASC
50 – FQHC
72 - RHC
E&M SERVICE
• The accurate assignment of POS codes ensures that claims
are processed correctly and efficiently, maintaining proper
documentation for healthcare services provided.
PREDOMINAT OF E&M SERVICE
• It also ensures compliance with guidelines from entities like
the Centers for Medicare & Medicaid Services (CMS),
minimizing the risk of audits and claim denials
• Proper E&M coding reflects the complexity and level of
care required during patient encounters, which is
determined by factors such as the patient’s medical history,
the nature of the presenting problem, the decision-making
involved, and the time spent with the patient.
E&M SERVICE
• Accurate E&M coding is vital not only for
reimbursement purposes but also for maintaining
compliance with regulations set by insurance
companies and the CMS.
• Incorrect coding can lead to denials, overpayments,
or even legal consequences for healthcare providers.
Therefore, understanding the guidelines for E&M
codes,
• including the definitions of key components like
history, examination, and MDM, is essential for
coders, healthcare providers, and billing personnel.
E&M SERVICE
• As the healthcare industry continues to evolve,
particularly with the implementation of ICD-10 and
other coding systems, staying up to date with E&M
coding guidelines is crucial.
• Ongoing education and training for medical coders
will help ensure accurate coding, streamlined claims
processing, and proper reimbursement, ultimately
leading to better healthcare delivery and financial
management in medical practices.
