5.3 Coding Evaluation and Management Services

1. 5.3 Coding Evaluation and Management Services 5-12 E/M Codes • Cover physicians’ services performed to determine the optimum course for patient care • New or established patient • Place of service • Referral • Consultation • Remember the three Rs of consults: request opinion, render service, report back. • Medicare does not pay consult codes. • Level of service • extent of the patient history taken • extent of the examination conducted • complexity of the medical decision making

2. 5.3 Coding Evaluation and Management Services Cont. 5-13 Eight Steps for E/M Code Assignment • Determine the category and subcategory of service based on the place of service and the patient’s status. • Determine the extent of the history that is documented. • History of Present Illness (HPI) • Review of Systems (ROS) • Past Medical History (PMH) • Family History (FH) • Social History (SH) • Determine the extent of the examination that is documented.

3. 5.3 Coding Evaluation and Management Services Cont. 5-14 Eight Steps for E/M Code Assignment Cont. • Determine the complexity of medical decision making that is documented. • Analyze the requirements to report the service level. • Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination. • Verify that the documentation is complete. • Assign the code.

4. 5.3 Coding Evaluation and Management Services Cont. 5-15 Reporting E/M Codes on Claims • documentation guidelines for evaluation and management • office and hospital services • emergency department services • preventive medicine services