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Evaluation and Management
Codes
Justine Strand, MPH, PA-C
Patricia Castillo, MS, PA-C
Victoria Kaprielian, MD
Basics of E&M coding
• history
• physical examination
• medical decision making
• time
Categories of E&M codes
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Outpatient
Inpatient
Consultation
Emergency department
Categories of E&M codes, cont’d
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Nursing home
Rest home
Home visits
Other
Levels of codes
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Problem focused
Expanded problem focused
Detailed
Comprehensive
History levels
• Problem focused (PF)
– chief complaint
– brief HPI
• Expanded problem focused (EPF)
– CC, HPI
– problem-pertinent ROS
History, continued
• Detailed (D)
– CC, HPI
– extended ROS
– pertinent PMH, FH, or SH
• Comprehensive (C)
– CC, HPI
– complete ROS, PMH, FH, SH
History examples: asthma
• PF: Breathing fine, no complaints
• EPF: include medication use, recent URI sx
• D: add assessment of exposure to allergens,
family hx asthma, some ROS
• C: lifelong history of asthma; full PMH,
FH, SH, ROS
Exam levels
• Problem focused (PF)
– affected body area or organ system
• asthma example: lungs
Exam levels, continued
• expanded problem focused (EPF)
– above plus
– other symptomatic or related organ systems
• example: lung exam plus ENT or heart
Exam, continued
• Detailed (D)
– extended exam of affected body area and
related organ systems
• exam of lungs, ENT, cardiovascular, and
extremities
Exam, continued
• Comprehensive (C)
– complete multi-system exam
• complete exam
Basics of E&M coding
• history
• physical examination
• medical decision making
• time
Elements of
medical decision-making
• number of diagnoses and management
options to be considered
• amount and complexity of data reviewed
– labs
– prior records
– consultant reports
• risk level:
complications, morbidity,
mortality
Diagnoses and decision-making
• Beware of “coding by diagnosis”
Medical decision-making
Level complexity
Data
reviewed
Minimal
Risk
Straight-forward
Dx/tx
options
Minimal
Low
Limited
Limited
Low
Moderate
Multiple
Moderate
Moderate
High
Extensive
Extensive
High
Minimal
Decision-making examples
1. doing fine, no change
2. check peak flow, adjust medications
3. nebulizer treatment with peak flows before and
after, review past levels, add steroid, discuss
criteria for urgent care
4. start home nebs, oral steroids; review hospital
chart; discuss medication side effects and risks;
consider hospitalization, discuss criteria for ER
Other factors
• New vs. established patient
– new = not seen within 3 years
– documentation requirements stricter (3/3)
Other factors
• time
– lesser element
– use if counseling > 50% of encounter
– document face-to-face time
Putting it together:
established pts
• Requires 2 of 3 elements
History
Exam
MDM
Face-toface
99211
supervision
only
supervision
only
Stfrwd
5 min.
99212
99213
PF
EPF
PF
EPF
Stfrwd
Low
10 min.
15 min.
99214
D
D
Moderate
25 min.
99215
C
C
High
40 min.
Putting it together: new pts
• Requires 3 of 3 elements
History
Exam
MDM
Face-toface
99201
PF
PF
Stfrwd
10 min.
99202
EPF
EPF
Stfrwd
20 min.
99203
D
D
Low
30 min.
99204
C
C
Moderate
45 min.
99205
C
C
High
60 min.
Common errors
• Undercoding
• Overcoding
Other settings
• Same system
• Different specifics
Health Maintenance
Age
New pt
Established pt
Less than 1 year
99381
99391
1-4 years
99382
99392
5-11 years
99383
99393
12-17 years
99384
99394
18-39 years
99385
99395
40-64 years
99386
99396
65 and over
99387
99397
Procedures
• Procedure only visits
• Combined procedure and E&M visits
• Modifier -25
Modifier 25
• Health maintenance visits
• Reimbursement issues
Prolonged services
• Face-to-face
• Other
Prolonged services
• Examples
How it works in practice
• Each practice develops their own system
• Encounter forms--provider marks with:
– charge code(s)
– diagnoses
– procedures/tests/therapies performed
What if you get it wrong?
• undercoding
• overcoding
Summary
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Code for what you do
Document in sufficient detail to justify level
Be as specific as possible
Include diagnoses appropriate for every
service delivered
• Remember modifiers when needed
• Keep learning!