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Evaluation and Management Codes

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. Outpatient Inpatient Consultation Emergency department.

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Evaluation and Management Codes

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  1. Evaluation and Management Codes Justine Strand, MPH, PA-C Patricia Castillo, MS, PA-C Victoria Kaprielian, MD

  2. Basics of E&M coding • history • physical examination • medical decision making • time

  3. Categories of E&M codes • Outpatient • Inpatient • Consultation • Emergency department

  4. Categories of E&M codes, cont’d • Nursing home • Rest home • Home visits • Other

  5. Levels of codes • Problem focused • Expanded problem focused • Detailed • Comprehensive

  6. History levels • Problem focused (PF) • chief complaint • brief HPI • Expanded problem focused (EPF) • CC, HPI • problem-pertinent ROS

  7. History, continued • Detailed (D) • CC, HPI • extended ROS • pertinent PMH, FH, or SH • Comprehensive (C) • CC, HPI • complete ROS, PMH, FH, SH

  8. 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

  9. Exam levels • Problem focused (PF) • affected body area or organ system • asthma example: lungs

  10. Exam levels, continued • expanded problem focused (EPF) • above plus • other symptomatic or related organ systems • example: lung exam plus ENT or heart

  11. Exam, continued • Detailed (D) • extended exam of affected body area and related organ systems • exam of lungs, ENT, cardiovascular, and extremities

  12. Exam, continued • Comprehensive (C) • complete multi-system exam • complete exam

  13. Basics of E&M coding • history • physical examination • medical decision making • time

  14. 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

  15. Diagnoses and decision-making • Beware of “coding by diagnosis”

  16. Medical decision-making

  17. Decision-making examples • doing fine, no change • check peak flow, adjust medications • nebulizer treatment with peak flows before and after, review past levels, add steroid, discuss criteria for urgent care • start home nebs, oral steroids; review hospital chart; discuss medication side effects and risks; consider hospitalization, discuss criteria for ER

  18. Other factors • New vs. established patient • new = not seen within 3 years • documentation requirements stricter (3/3)

  19. Other factors • time • lesser element • use if counseling > 50% of encounter • document face-to-face time

  20. Putting it together: established pts • Requires 2 of 3 elements

  21. Putting it together: new pts • Requires 3 of 3 elements

  22. Common errors • Undercoding • Overcoding

  23. Other settings • Same system • Different specifics

  24. Health Maintenance

  25. Procedures • Procedure only visits • Combined procedure and E&M visits • Modifier -25

  26. Modifier 25 • Health maintenance visits • Reimbursement issues

  27. Prolonged services • Face-to-face • Other

  28. Prolonged services • Examples

  29. How it works in practice • Each practice develops their own system • Encounter forms--provider marks with: • charge code(s) • diagnoses • procedures/tests/therapies performed

  30. What if you get it wrong? • undercoding • overcoding

  31. Summary • 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!

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