E&M Coding Advice

Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That's because, by their nature, E&M services are a diverse set of cognitive procedures, making them difficult to quantify.

The medical directors at TrailBlazer Health Enterprises offer the following highly simplified but very useful "bottom-line" E&M coding advice. (Read a  more in-depth look at E&M coding  from the medical directors, too.)

Regardless of how much history, physical examination, and/or medical decision-making related to an E&M encounter are recorded …

  • Do not consider reporting the highest two codes of any code family:
    • When fewer than three distinct medical conditions/complaints  were evaluated and managed during the encounter,
      OR
    • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of the current encounter and the next physician encounter. 
     
  • Do not consider reporting the highest codes of any code family:
    • When fewer than four distinct medical conditions/complaints  were evaluated and managed during the encounter,
      OR
    • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of that encounter and the next physician encounter. 
     

This approach simplifies coding E&M services by eliminating from consideration the highest-level codes for reporting services that - by their clinical nature - usually do not require a detailed or comprehensive history and physical, high- (and sometimes moderate-) complexity medical decision making, or lengthy counseling and coordination. It addresses the most common source of known Medicare E&M coding errors: failure of medical records to demonstrate the work of and/or medical necessity of higher level E&M services reported for payment.

 

TMA Practice E-tips main page