TOPIC ON E/M(EVALUATION AND

MANAGEMENT

It covers patient disease, history, exam, and MDM(medical decision making).

80% of cpt codes covers E/M services.Assign E/M code whenever there is a

documentation of history examination and MDM.

E/M code covers 10k-6k series with respective modifiers

INTRODUCTION

Based upon place of service(office visits,hospital visits,consultations)

Based upon ageTime taken for assessment Office visits again subdivided as new

patient(or) established patientHospital visits again sub divided as initial(or)

subsequent patient.

CLASSIFICATION OF E/M SERVICES

If time dominates a visit(taking too much time in assessing a patient) assign separate code with respect to time.

Classification is very important because nature of work varies based on type of service place of service and patient condition.

7 major componentsHistoryExaminationMDM(medical decision making)TimeCounselingCo-ordination of careNPP(nature of presenting problem)

COMPONENTS OF E/M SERVICES

First 3- components are key componentsRest of 4- components are contributory

components.LEVELS OF E/M SERVICE:-

it designed as i. Giving unique code numberii. Mentioning place/type of service providediii. Content of the serviceiv. Finding present problemv. Time taken for MDM decision.

New patient visit requires more time than established patient

More resources are required for new patientFor new patient Payment may be 40% higher

than established patientSeparate codes are available for new and

established patientsPatient come back within 3 years of time

considered as established patient

NEW/ESTABLISHED PATIENT

3 years is the considering factorAbsence of specification assume it as

established patientHOW TO ASSIGN E/M CODE?Analyze the patient(new/established)Place of serviceAgeTimeKey components

8- elements are listed they areLocationDurationSeverityQualityAssociated signs&symptomsTimeModifying factorscontext

ELEMENTS OF HPI(history of present illness)

If 3- elements are documented, (HPI is brief)Example: abdominal pain since morning

due to spicy foodIf more than 3- elements documented,(HPI is

expanded).Example :edema of both legs due to ckd

with diabetic foot since 4 months and k/c/of diabetic&hypertension since 5 years.

Payment difference for every element is 10 dollars.

Pay&chase model:-insurance company pay first later on chase.

Self-disclosure scheme:-under this scheme physician can declare self errors and publish there by refunds the money to insurance companies

It is a questionnaire where patient has to respond

There are 11- ros are there:-EYEENTCardiovascularRespiratorygastrointestinal

REVIEW OF SYSTEMS(ROS)

GenitourinaryMusculoskeletalIntegumentary neurologicalneurologicPsychiatricHematologic/lymphatic

Physical exam is objective evidenceROS is subjective evidenceNATURE OF PRESENTING PROBLEMS They are 5-typesMinimalSelf-limitedLow severityModerate severityHigh severity

HISTORY EXAMINATION MDM(LEVEL)

PROBLEM FOCUSED

PROBLEM FOCUSED

STRAIGHT FORWARD

EXPANDED EXPANDED LOW LEVEL COMPLEXCITY

DETAILED DETAILED MODERATE LEVEL COMPLEXICITY

COMPREHENSIVE

COMPREHENSIVE

COMPREHENSIVE

Classification of history,examinantion,MDM.

Physical exam is done by four waysInspection(seeing)Palpation(touching)Auscultation(hearing)Percusion(tapping)

There are 2- types of guidelines for E/M coding

1995-guidelines1997-guidelinesCpt book has 1995-guidelinesAuditors preffers 1997-guidelines1995-guidelines based on history and MDM1997-guidelines based on bullet points

If there is no specific mention code as established patient

Considering three key factors(history/exam/MDM)

If a level is not matching, as per CPT guidelines drop the level

SELECTION OF E/M SERVICE CODING

For new patient 3/3 levels should be match

For established patient2/3 levels is minimum

Dollar value depends on physician+practice+malpractice insurance.

Time is a considering factor for E/m servicesIt includes both new/established patientsMinimum 8- hours are required for

discharging a patient on same dayDay-1 considered as initial hospital careDy-2 is subsequent dayDischarge is based on time.

HOSPITAL OBSERVATIONAL SERVICES

It is a type of service, in this service one physician can refer another physician for a specific condition

Consultant physician can start diagnosing the patient or therapeutic services subsequently.

Such services are reported under office visit,home service,etc….

Written format for consult physician may made by a physician are documented in patient medical records..

CONSULTATIONS

This code are given only when treatment or services done in emergency department.

Case must be seen by emergency physicianEmergency department must be 24/7New/established patients included.Critical care services provide in ED reported

separately

EMERGENCY SERVICES

Time is not a discriptive factor in ED

ED service coding given based upon intensity.

It may involves multiple encounters

So time is not a considering factor

Critical care is given by direct physician or any other health care professionals

Monitoring vital signs are very importantIt requires high complexity decisionIt depends on total duration of timeIf less than 30- minutes use appropriate E/M

services.

CRITICAL CARE

Critical care provided to 29 days to 71 months

code from pediatric critical care.

Critical care is provided with other E/M services code separately

Range of code 99291-99292.

Nursing facility service codes given when E/M services are at skilled nursing facilities.

This codes also used for psychiatric residential treatment center.

If any other services are along with this code separately.

NURSING FACILITY SERVICES

Prolonged services without direct patient codes are 99358-99359.

Preventive medicine services are include infants,children, and adults

Range of code for new patient 99381-99387Range of code for established patient 99391-

99397Telephonic services are not face-to- face

services

Telephonic services are given through telephone

Range of code 99441-99443On line medical evaluation is by physician to

patient through internet sourcesRange of code 99444https://www.medesunglobal.com/

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