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Basics of Evaluation and Management Coding

Mar 1, 2025

Introduction to Evaluation and Management Coding

Overview

  • Evaluation and Management (E&M) coding is complex due to:
    • Areas of uncertainty
    • Differences in interpretation across regions
  • This session focuses on the basics of E&M coding

Preparation

  • Have your 2019 or 2018 CPT coding manual
  • Start at the Evaluation and Management Services guidelines section
  • Review 1995 and 1997 E&M guides from CMS
    • Providers can choose which guideline to use based on practice policy

Key Components of E&M

  1. History
  2. Exam
  3. Medical Decision Making (MDM)

Additional Components

  • Contributing factors may also be used depending on services
  • Some E&M codes are based on time or specific characteristics

Steps in E&M Coding

Step 1: Determine Range of Codes

  • Identify type of service (consultation, office visit, etc.)
  • Determine place of service
  • Assess patient status (new or established)
  • Use CPT manual index to locate code range

Step 2: Determine History Level

  • Four levels: Problem-focused, Expanded Problem-focused, Detailed, Comprehensive
  • Elements:
    • Chief Complaint (CC)
    • History of Present Illness (HPI)
    • Review of Systems (ROS)
    • Past, Family, and Social History (PFSH)
  • Quantification of HPI:
    • Brief: 1-3 elements
    • Extended: 4+ elements or status of 3+ chronic conditions

Step 3: Determine Exam Level

  • Four types: Problem-focused, Expanded Problem-focused, Detailed, Comprehensive
  • 1995 vs 1997 guidelines for exam specifics
  • Exam can be body areas or organ systems
  • Comprehensive exams require 8+ organ systems or complete single system

Step 4: Medical Decision Making

  • Measured by:
    1. Number of diagnoses or treatment options
    2. Amount and complexity of data reviewed
    3. Risk of complications or morbidity/mortality
  • Table of Risk: Minimal, Low, Moderate, High
  • Use highest level of risk across all three columns
  • Two of three elements in decision-making table must be met or exceeded

Step 5: Pull it Together

  • Combine history, exam, MDM to select final code
  • New patient codes require all three components; established patient codes require two

Coding Based on Time

  • Total time face-to-face or floor time must be documented
  • Counseling and coordination of care should dominate more than 50% of service

Final Notes

  • Consistent policy for E&M coding is essential
  • Use tools and guidelines consistently for practice
  • Further research and practice are necessary to master E&M coding

Full transcript