Coding medical procedures and diagnoses can be a daunting task if you are not educated in this field. I am going to break down the rules for evaluation and management (E/M) coding, so take a deep breath and let’s jump in!
First, identify what type of E/M service is being performed. There are different rules for each type of visit and, as with all coding, the devil is in the details.
- New patient versus established patient. A patient is considered new if it is the first time the physician has seen the patient and the patient has not been seen by anyone in the practice with the same specialty within three years.
- Consultation versus referral. Although Medicare no longer reimburses for consultation codes, some private payors still do. A visit is considered a consult if the referring physician is asking for medical advice or opinion. It is a referral if the physician wants the specialist to take over care of a certain disease.
- Outpatient versus inpatient. The place of service determines this distinction. If the service is done in the office or in the outpatient department of the hospital, then the patient is considered to be outpatient. If the patient is admitted into the hospital, then the place of service is considered inpatient. Keep in mind that even if the patient is in the hospital for more than 24 hours and not admitted, the service is coded as outpatient or observation.
- Initial versus subsequent. For Medicare patients, it is permissible to bill for an initial visit if it is the first time the rheumatologist has seen the patient for that visit, even if the patient has been seen in practice in the past. This is allowed even if other physicians have examined the patient during this same visit. Each time the rheumatologist sees the patient during the same visit, it must be coded as subsequent.
Once the determination has been made as to the type of E/M visit, it is time to decide on the level of the visit. All E/M visits are composed of three elements: history, examination, and medical decision making. Some visits need all three elements and some only need two of the three to obtain the level of coding—this will depend on the patient type.
Established patients, subsequent observation, and subsequent inpatient visits only need two out of the three elements to achieve the level of the visit. New patients, inpatient and outpatient consultation, emergency room, initial observation, and initial inpatient hospital visit require all three elements.
History
The history is made up of four components: chief complaint, history of present illness, review of system, and past family social history (PFSH). All four components must be documented to determine the history level:
- Problem-focused;
- Expanded problem-focused;
- Detailed; or
- Comprehensive.
Failure to document any one of the four will lead to lowering the level of the history. For example, if the PFSH is not recorded, the highest level the history can be is expanded problem-focused, but if all of the PFSH is recorded the level could be determined to be comprehensive.
Examination
There are two sets of guidelines of examination allowed for documentation, 1995 and 1997 guidelines, but they cannot be interchanged during a visit. There are four levels for both guidelines:
- Problem-focused;
- Expanded problem-focused;
- Detailed; and
- Comprehensive.
For a general multisystem exam, the 1995 guidelines recognize the following: