How to Nail Down Levels of E/M Services & Secure Optimal Reimbursement

Posted on 17 May, 2018 |comments_icon 0|By Elizabeth
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Like all CPT® codes, E/M codes are universal and used by Medicare, Medicaid, and most other payers for processing claims for a physician’s professional services. You should also use E/M service codes for billing facility services on an outpatient basis.

Because evaluation and management services are high-volume provider activities, the E/M codes are the most frequently used by physicians and nonphysician providers in daily practice. They are also prone to the most errors, resulting in high claim denial rates and lost revenue.

Determining Levels of Physical Examinations During E/M Services

The levels of E/M services constitute wide variations in change in skills, time, effort, responsibility, and medical knowledge.

The actual performance and/or interpretation of diagnostic studies ordered during a patient encounter are not included in the E/M service levels. You may separately report your provider’s performance of diagnostic studies for which specific CPT® codes are available, in addition to the appropriate E/M code. You may also separately report the provider’s interpretation of diagnostic studies results with preparation of a separate distinctly identifiable signed written report using the appropriate CPT® code with modifier 26 (Professional component).

If you found that the patient’s condition required a significant separately identifiable E/M service beyond other services provided or beyond the postop care associated with the procedure that was performed, you can be report it by adding modifier 25 to the appropriate E/M service for which the service was provided. In this case, different diagnoses are not required for reporting of the procedure and E/M services on the same date.

Using either the 1995 or 1997 guidelines, you should measure physical examinations during E/M services using the following standards:

  • A problem-focused examination, according to the 1995 guidelines, is a limited examination of the affected body area or organ system (one body area or organ system). The 1997 guidelines state that a problem-focused exam consists of performing and documenting one to five elements identified by a bullet in the following chart (or specific specialty exam where appropriate).
  • An expanded problem-focused examination is defined by the 1995 guidelines as a limited examination of the affected body area or organ system and other symptomatic or related organ system(s) (two to seven body areas or organ systems). The 1997 guidelines state that this consists of performing and documenting at least six elements identified by a bullet in the following chart (or specific specialty exam where appropriate).
  • A detailed examination is defined by the 1995 guidelines as an extended examination of the affected body area(s) and other symptomatic or related organ system(s) (two to seven body areas or organ systems with at least one body area examined in more detail). The 1997 guidelines state this consists of performing and documenting at least two elements identified by a bullet from each of six areas/systems and at least 12 elements identified by a bullet in two or more areas/ systems for the general multi-system exam. See the following chart for bullets (or specific specialty exam where appropriate).
  • A comprehensive examination, the 1995 guidelines state, is a complete general multi-system examination or an examination of a single organ system (eight or more organ systems). The 1997 guidelines indicate that this consists of performing all elements identified by a bullet in at least nine organ systems or body areas and documenting at least two elements identified by a bullet from each of nine areas/systems for the general multisystem exam. See the following chart for bullets (or specific specialty exam where appropriate).

The following is an example of how a provider uses E/M codes on a day-to-day basis:

A cardiologist sees a new patient for a cardiology consultation in an outpatient clinic setting. To bill the rendered service, the cardiologist must select E/M code category 99241- 99245 (Office consultation for a new or established patient…), and then select the appropriate level of E/M service from one of the category’s five levels.

To determine the appropriate E/M code, the provider must make a judgment regarding the patient’s condition for each key service element—patient history, examination, and medical decision-making (MDM). Then, the provider must make more judgments about the nature and extent of work he provides.

The E/M service levels recognize four types of MDM—straightforward, low complexity, moderate complexity, and high complexity. Identifying the appropriate type requires another three layers of decisions to determine. CPT® states MDM is based on two out of the following three levels:

  1. The number of diagnoses or care options rated as minimal, limited, multiple or extensive
  2. The amount and/or complexity of data to be reviewed as minimal, limited, moderate or extensive
  3. The risk of complications and/or morbidity/mortality as either minimal, low, moderate, or high in accordance with the assessment of the patient’s presenting problems, diagnostic procedures ordered and management options and as outlined on the Table of Risk in CPT®’s E/M guidelines

Aggregate all determinations and select a level. If, for example, a cardiologist performs a comprehensive history, a comprehensive exam, and medical decision-making of high complexity, then she would be able to bill 99245, the highest level consultation code.

Like new patients, however, consultations also require three out of three elements. So if the cardiologist performs a comprehensive history, detailed exam, and MDM of high complexity, the level documented would only be 99243.

Extended History Status

Using the 1997 guidelines—which allow a provider to use the status of three or more chronic conditions, provided he mentions the status and attention to those chronic illnesses—might result in reporting higher-level services for patients who have chronic conditions. The provider must indicate the status of these and any information about these conditions to code a higher-level E/M service for encounters that involve periodic prescription renewals without the provider having to go into as much detail. If the provider mentions only the chronic illnesses, you cannot use this type of history of present illness (HPI). The history’s review of systems (ROS) section must still meet the service level being billed and be medically necessary.

Example: A Medicare patient who has controlled benign hypertension (I10, Essential (primary) hypertension), controlled type 2 diabetes (E11.9, Type 2 diabetes mellitus without complications) and severe allergies (J30.0, Vasomotor rhinitis) presents for a follow-up of his hypertension and diabetes. After an appropriate exam, the provider renews the patient’s prescription and notes:

  • Hypertension—active, stable with current medication renewed.
  • Diabetes—active, stable on metformin 500 mg b.i.d., renewed. Hay fever (J30.9, Allergic rhinitis, unspecified)—active, stable with over-the-counter medication. Because the provider indicates the status of at least three chronic or inactive conditions, using the 1997 guidelines leads to an extended HPI. When combined with an appropriate ROS and past, family, and social history, the extended HPI can result in a detailed history. If the provider performs either a detailed examination or moderate-complexity medical decision-making, report the encounter with 99214.
  • Remember: Medical necessity should ultimately drive the visit’s history and examination.

Learn More

Evaluation and management coding is challenging and often leads to claim denials. You need to know CPT® guidelines, understand level of service, possess modifier know-how, and stay current on regulations and documentation guidelines.

It’s time to untangle your E/M coding troubles with straightforward solutions. Protect the financial health of your practice with TCI’s Evaluation & Management Coding Handbook 2018.

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Elizabeth


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