Over the last few decades, emerging technological advancements in medicine have drastically revolutionized the way we view the healthcare system. Recent breakthroughs and innovations in data collection, research, and treatments have significantly increased the operational efficiency in the healthcare practice as well as improved patient outcomes.  One such effective tool that is at the core of clinical practice is E&M coding that has cultivated a significant shift to electronic health records. But what are E&M codes?

What Are E&M Codes?

E&M or ‘evaluation and management’ codes are a set of five-digit codes ranging from 99202-99499. Each set represents a different service provided by a healthcare professional and is submitted to insurance companies in order to facilitate the process of billing.

Each code describes a different patient-physician encounter based on several different levels of care and the complexity of the patient’s visit. There are specific documentation requirements for E&M coding that need to be satisfied with every billable procedure before being submitted to the insurers for reimbursement. These requirements for each E&M code in the E&M codes list are dictated by a set of structured guidelines that were drafted by the Centre for Medicare and Medicaid Services called the E&M guidelines.

Challenges of E&M Coding

With the convenience, accuracy, and time-saving benefits that come with electronic health record documentation via E&M coding also come the complex rules and criteria for selecting an appropriate E&M code. The selection requires a high degree of clinical judgment, which is why it is common for experts to disagree over the E&M code for a given physician-patient encounter. E&M coding is a highly complex process and thus, it is important for the clinic staff to be extensively trained in order to ensure accurate billing of the insurance company.

Owing to the complexity of E&M coding, it is imperative that physicians have a working knowledge of it and they maintain detailed documentation regarding each healthcare service that they provide. The slightest errors in coding or documentation can result in significant compliance and payment issues.

To ensure proper billing, optimal compliance, and accurate coding, physicians need to understand the rules of E&M coding and how to properly document their services. Several physicians are under-coding for their services because they simply lack an understanding of the intricacies and complexities associated with choosing the appropriate E&M code. A study by the Department of Health and Human Services indicates that 42 percent of claims for E&M services in 2010 were incorrectly coded with 19% lacking adequate documentation. These improper coding claims included both up-coding and down-coding, with the majority of the incorrect claims being down-coded. This means that several medical facilities and practitioners are not claiming the revenue that they are entitled to.

Components of E&M Coding

Staying up to date on the E&M coding and documentation rules and knowing how to accurately bill for their services can allow physicians to maximize the revenue that they deserve. Several factors are involved in selecting the correct code from the E&M codes list. For this reason, several different components of the E&M service have to be taken into consideration by the coder to ensure faultless coding.

Here are the seven key components as per the E/M guidelines used in the descriptors of E&M codes:

1. History

History is one of the three key components of E&M coding to be documented, which is used in defining the levels of E&M services. Not only does the history provide insight into the patient’s history of the present illness (HPI) if any, but it also documents any prior illnesses or medical conditions that the patient might have. The history also documents the patient’s family and social history and records a review of systems according to the patient’s perspective in addition to their chief complaint (the primary reason for the patient’s visit).

2. Examination

The examination is a professional assessment and evaluation of the patient’s body and organ systems by means of inspection, palpation, auscultation, and percussion. The examination along with the patient’s history constitutes a complete health assessment that assists the physician in determining the right diagnosis of the patient’s chief complaint and helps them devise the best treatment procedure.

Examinations are divided into four types to ease the process of documenting the E&M service:

  • Problem-Focused: A limited evaluation of the patient’s affected body area or organ system.
  • Expanded Problem-Focused: An extended form of the problem-focused examination which also includes a limited examination of any other symptomatic or related body areas or organ systems in addition to the affected area.
  • Detailed: An in-depth examination of the affected body area or organ system and any other related areas or systems.
  • Comprehensive: A general and extensive examination of several systems or a thorough examination of one organ system.

3. Medical Decision Making (MDM)

This is the most important component that determines the E&M code of service. It reflects the intensity of work put in by the physician(s) in establishing a diagnosis and formulating a treatment plan.

MDM is divided into four levels based on their complexity:

  • Straightforward
  • Low Complexity
  • Moderate Complexity
  • High Complexity

The MDM must be classified into one of these four levels based on:

  • The number of possible diagnoses and treatment options considered;
  • The complexity of the data analysed and reviewed by the physician; and,
  • The risk of morbidity and/or mortality associated with the patient’s condition.

4. Counselling

Counselling is an important component that needs to be taken into consideration when determining the appropriate code from the E&M codes list but only when counselling/coordination of care dominates more than 50% of the time with the patient. Counselling refers to discussions with a patient and/or any related parties (family members, guardians, etc.) regarding the patient’s diagnosis, prognosis, management options, and the risk factors associated with the treatment options.

5. Coordination of Care

Many physicians spend a significant amount of their time coordinating their patient’s care. Coordination of care is the process of communicating with other practitioners regarding the patient’s problem and their family’s needs. Everything that is discussed should be documented in detail along with the time of encounter in order to support that more than 50% of the time was spent in the coordination of care and counselling.

6. Nature Of Presenting Problem

When choosing an E&M code, the gravity of the patient’s condition plays a key role in determining the extent of the examinations performed on the patient and the level of service.

The nature of the presenting problem is divided into five levels based on the severity of the problem:

  • Minimal
  • Self-Limited/Minor
  • Low Severity
  • Moderate Severity
  • High Severity

7. Time

Time may be the crucial component determining the level of an E&M service and its subsequent code when over 50% of time spent with a patient is spent in counselling or coordination of care for a patient. In such a case, time becomes the key factor controlling the selection of the E&M code. When time is used as the controlling factor, the coder must document the total face-to-face time spent with the patient, time spent in counselling or coordination of care, and the nature of counselling or coordination of care.

See Also: Determining Mental Health Using Patient Health Questionnaire PHQ9

Bottom Line

Accurate and reliable medical records are at the crux of any successful medical practice. This is why E&M coding is an integral part of any clinical practice but with so many services being improperly coded leading to a loss in revenue, the coded and documented data must be as valid and reliable as possible. Thus, understanding the rules of E&M coding using these 7 components is essential to coding accurately for different patient-physician encounters.

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