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Evaluation & Management Coding

This document provides an overview of Evaluation and Management (E/M) coding. It discusses the key components used to determine the level of E/M services, including history, exam, and medical decision making. The document outlines the 1995 and 1997 CMS documentation guidelines for E/M codes and explains how to evaluate a patient encounter and select the appropriate E/M code based on the extent of documentation and medical necessity of the visit. Proper documentation of E/M components is essential for generating the correct level of service code.

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1K views14 pages

Evaluation & Management Coding

This document provides an overview of Evaluation and Management (E/M) coding. It discusses the key components used to determine the level of E/M services, including history, exam, and medical decision making. The document outlines the 1995 and 1997 CMS documentation guidelines for E/M codes and explains how to evaluate a patient encounter and select the appropriate E/M code based on the extent of documentation and medical necessity of the visit. Proper documentation of E/M components is essential for generating the correct level of service code.

Uploaded by

sherrij1025
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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EVALUATION &

MANAGEMENT CODING
Presented by: Sherri Jurysta
Focus of this Presentation
 Introduction to Evaluation & Management (E/M)
codes – located in CPT Manual
 Guidelines established by CMS
 1995 Guidelines
 1997 Guidelines
 Components of E/M coding
E/M Codes
 Used for non-surgical/procedural services
 E/M codes are divided into three categories
 Office visits, Hospital visits, and Consultations
 Most categories include subcategories
 Further identified by level of service – identified by codes
 Other subsections of E/M include:
 Hospital in patient
 Consultation
 Critical care
 Pediatric and Neonatal critical care
 Emergency care
 Preventative Medicine
E/M Codes
 Three “key” components to determine level of service –must
be substantiated in the documentation
 History
 Physical Exam
 Medical Decision Making
 Time – only when 50% or more of the visit is documented
counseling and/or coordination of care
 Specified documentation is best for generating the proper
level of service code – “if it is not documented, it did not occur.”
E/M Documentation Guidelines
 Guidelines are provided by CMS
 1995 and 1997 E/M Documentation Guidelines

 http://www.cms.gov
 Providers can use either system – variance is in the determination of the key
components
EXPANDED
PROBLEM
PROBLEM DETAILED COMPREHENSIVE
FOCUSED
FOCUSED
1997 1-5 bullets 6-12 bullets 12 bullets >/= 2 bullets for each of 9
areas/ systems OR “all”
elements in a single system

1995 1 body 2-7 body areas/ 2-7 body areas/ 8 or more systems OR
area/system systems systems, more complete single system
( 2, 3, or 4 systems) detail
(5, 6, or 7 systems)
Components of E/M Codes

“KEY” COMPONENTS “CONTRIBUTORY” COMPONENTS

 History  Counseling
 History of present illness  Discussing results, prognosis, treatment
options, ect. with patient and/or family
 Review of systems
 Past, Family and social history
 Coordination of Care
 Making arrangements with other
 Exam providers
 1995 or 1997 standards  Nature of presenting Problem
 Medical Decision Making  Included with amount of diagnoses in
 Amount of diagnoses MDM
 Amount/complexity of data  Time (clearly documented)
 Risk (determined by provider)  Face to face
 Unit/ floor time
Abstracting the Components

 EM_Worksheet_Aqua[1].pdf
 CMS uses an audit tool to confirm the correct level of service
was billed –
 Attached to hand out
 E/m worksheets are available
 Checklists for the provider to use during a visit are helpful
 Volume of documentation is not the sole influence for the
level of service. The reason the patient presented is also
considered when determining medical necessity of the
encounter.
History Components
 HPI – History of Present Illness
Elements of HPI
Quality Location
Duration Severity
Timing Context
Modifying Factors Associated Signs/Symptoms

 ROS – Review of Systems


 Determine the amount of systems reviewed
 PFSH = Past, Family, and Social History
 Illnesses, surgeries, injuries, family diseases, and current/past
activites
Examination Components
 Will vary based on guideline being used
 1995 guideline is based on systems
 1997 guideline is calculated by bullets
 General Multispecialty exam
 Single Specialty (various)
 Attach worksheet shows both elements
 Often missed – “General appearance, gait and station,
judgment, oriented x3; mood and affect…..”
 All performed without “hands-on” exam.
MDM, Data & Risk Components
 The extent of information documented determines the
level of decision making
 Number of Diagnoses or treatment options
 Minor, established, or new
 Data
 Review/ discuss labs, tests, old records
 Risk
 Refers to level of risk at time of visit
 Complications, morbidity, and/or mortality
Selecting an E/M code
 Determine the category based on location
 Determine subcategory – situational
 Review record for “key” components
 Take note if there are “contributory” components
 Analyze the information and assign proper code
 Level of service reported MUST reflect the medical necessity
of the visit.
 Example – treatment of a skinned knee would not qualify for a
comprehensive level of service- regardless of documentation.
Helpful Tips
 If you can't read it – neither can CMS
 If it is not documented – it did not happen
 If there is no signature - how do you prove who did it
 No date - when was it done
 No Chief Complaint - why was the service done
 Chart should include: who (patient name), what (chief complaint), when
(history), where (exam), how (medical decision making)
 Read and re-read the documentation guidelines
 Make sure documentation is legible and records are signed and dated
Thank You

Questions?

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