Evaluation and management services introduction
Evaluation and Management Services
Evaluation and Management codes are commonly referred to as E/M codes. These codes are used to reflect what the provider does during the time spent with the patient. To properly code for that, the medical assistant must apply different techniques from the basic steps outlined earlier. Assigning the correct E/M code includes the following:
- Identifying the following for the procedure or service:
- Section
- Subsection
- Category
- Subcategory
- Reviewing the reporting instructions and guidelines for the code chosen
Reviewing the level of E/M service:
- Determining the extent of the history obtained and the examination performed
- Determining the complexity of medical decision making
The E/M section is divided into broad subsections, such as office visit, emergency room visit, hospital visit, and consultation. These subsections are further divided into subcategories, which include the place where the services were rendered, such as these:
- Provider’s office
- Hospital emergency department
- Skilled nursing facility
- Patient’s home
- Patient status
- New
- Established
Part A, explains how to perform CPT coding for an office visit. Here are the first two steps for choosing an E/M code:
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Identify the place of service (POS).
-
Identify the patient status (new or established).
Identifying the place of service
The POS is the healthcare facility where the provider delivers care to the patient. The two most common places of service are “office” and “hospital.”
Identifying the patient status
The patient status choices are “new” or “established” patient. A new patient (NP) is one who has not received any professional services from the provider, or from another provider of the same specialty and subspecialty who belongs to the same group practice, within the past 3 years.
An established patient (EP) is one who has received professional services from the provider, or from another provider of the same specialty and subspecialty who belongs to the same group practice, within the past 3 years.
Commonly used place of service (POS) codes:
| Code | Name |
| 01 | Pharmacy |
| 11 | Office |
| 12 | Home |
| 13 | Assisted Living Facility |
| 14 | Group Home |
| 15 | Mobile Unit |
| 17 | Walk-In Retail Health Clinic |
| 20 | Urgent Care Facility |
| 21 | Inpatient Hospital |
| 22 | Outpatient Hospital |
| 23 | Emergency Room–Hospital |
| 24 | Ambulatory Surgery Center |
| 31 | Skilled Nursing Facility |
| 34 | Hospice |
| 51 | Inpatient Psychiatric Facility |
| 60 | Mass Immunization Center |
| 65 | End-Stage Renal Disease Treatment Facility |
| 71 | Public Health Clinic |
| 72 | Rural Health Clinic |
| 81 | Independent Laboratory |
Once the POS and patient status have been established, the next step in selection of an E/M code is to determine the level of service provided.
Determining the level of service provided
Key components
The three key components for determining the level of service for E/M coding are history, examination, and medical decision making. The four contributing factors are counseling, nature of the presenting problem, coordination of care, and time; these are all secondary considerations.
History
To understand the history levels, it is important to know the definition and components of the patient’s history. The history relates to the patient’s clinical picture and depends on the patient for answers to specific questions.
The following are the four levels of history taking:
- Problem-focused history: A problem-focused history concentrates on the chief complaint; it looks at the symptoms, severity, and duration of the problem. It usually does not include a review of systems (ROS) or the family and social histories.
- Expanded problem-focused history: The expanded problem-focused history includes the following:
- Symptoms, severity, and duration of the chief complaint
- Review of systems that relate to the chief complaint
Usually the past, family, and social histories are not included.
Detailed history: The detailed history includes the following:
- Chief complaint
- Extended history of present illness
- Problem-pertinent system review, including a review of a limited number of additional systems
- Pertinent past, family, or social histories directly related to the patient’s problems
Comprehensive history: A comprehensive history includes the following:
- Chief complaint
- Extended history of present illness
- ROS that is directly related to the problem or problems identified in the history of the present illness
- Review of all additional body systems, in addition to complete past, family, and social histories
Examination
The examination is the objective part of the patient’s visit. The provider examines the patient, obtains measurable findings, and makes notes referring to body areas or organ systems as follows:
- Body areas: Head, including face and neck; chest, including breasts and axillae; abdomen; genitalia, groin, and buttocks; and back, including spine and extremities
- Organs and organ systems: General (e.g., vital signs, general appearance); eyes; ears, nose, throat, and mouth; cardiovascular; respiratory; gastrointestinal (GI); genitourinary; musculoskeletal; skin; neurologic; psychiatric; and hematologic, lymphatic, and immunologic
The examination is divided into the following levels:
- Problem-focused examination: The examination is limited to the affected body area or single system mentioned in the chief complaint.
- Expanded problem-focused examination: In addition to the limited body area or system, related body areas or organ systems are examined.
- Detailed examination: An extended examination is performed on the affected body area and related body areas or organ systems.
- Comprehensive examination: A complete multisystem examination is performed or a complete examination of a single organ system.
Medical decision making
When a provider makes medical decisions, the decisions are based on many years of education and experience. Three elements constitute the medical decision-making process:
- The number of diagnoses or management options. The provider’s notes during the history and examination should help identify whether the patient’s problem is minor, acute, stable, or worsening. The documentation should also identify whether a new problem exists or whether the provider plans to order any diagnostic tests to further investigate the patient’s illness or injury.
- The amount or complexity of data obtained, reviewed, and analyzed. The documentation should also identify what laboratory tests, x-ray diagnostic procedures, and other tests have been ordered or reviewed.
- The risk of significant complications or morbidity or mortality. Risk is often involved in medical care, either from the treatment given to the patient or from the lack of treatment and professional care. Morbidity, the relative incidence of disease, and mortality, which relates to the number of deaths from a given disease, are integral parts of the provider’s assessment of risks.
After considering those three elements, the complexity of medical decision making can be determined. The complexity of medical decision making is categorized into four levels: straightforward, low complexity, moderate complexity, and high complexity.
Other factors that contribute to E/M complexity
In addition to the key components, there are some additional factors that can influence the level of service when determining the correct evaluation and management code. Those factors are discussed next.
Counseling
Counseling is a discussion with a patient or family members about diagnostic results, impressions, recommended diagnostic studies, prognosis, risks and benefits of management or treatment options, instructions for management, treatment, or follow-up.
Almost all E/M services involve a degree of counseling with the patient or family. This is factored into the E/M code.
Nature of the presenting problem
The presenting problem is usually explained in the chief complaint. It can range from something as simple as a cold in an otherwise healthy patient to a life-threatening problem.
Coordination of care
Some patients need help in arranging for care beyond the visit or hospitalization. Some will need care in a skilled nursing facility or home healthcare. Others will need hospice care. The primary provider usually coordinates this care. Coordination of care is also factored into the E/M code and is a consideration for determining the level of service.
Time
Time alone can be used as a determining factor for selection of the correct E/M code. It is included in the E/M code descriptions The time requirement refers to a face-to-face encounter with the provider. The times stated in the code descriptions are averages.
At first, E/M coding can be difficult to understand and put into practice. The E/M coding process provided here can serve as a guide to help medical assistants in determining place of service, patient status, and level of care provided.
You can then select the most accurate E/M code. Using the clinical examples in Appendix C of the CPT manual and comparing them to the medical documentation also can help medical assistants acquire a better understanding of E/M coding.