Evaluation and Management

Coding for an office visit, home visit, hospital inpatient services and more are all found in the evaluation and management section.

It is of the utmost importance that Medical Coders be aware of the guidelines that are associated with E/M and how to level out an E/M code.

It can be overwhelming to new and experienced coders alike I am going to try to help make E/M an easier concept for you today!

Grab your CPT book and follow along… a video will be posted below too

Starting with Office and outpatient services

There are 5 levels of codes for new and established patients

according to the CMS website a new patient is

1. exam
2. history
3. medical decision making

you will need to know which set of guidelines your provider is using(I will link to the official guidelines below)

1995 or 1997 guidelines– according to the CMS a provider can choose which guidelines to follow, use the set of guidelines that are most beneficial to the provider

It will definitely help to have an E/M audit tool to help you get to the right level but this is a whole new post coming soon:) in this particular post I just want to give you a brief overview of the E/M section!

EXAM

HISTORY

This key component has a 8 sub-components

HPI(history of present illness)

1. location
   • where the patients chief complaint is located
     • example: patient presents with nasal congestion and headaches, post nasal drip
       • the location is in the head(respiratory system/ sinuses)
2. duration
   • how long has the symptoms been happening
     • example: the patient began suffering from congestion 5 days ago
3. timing
   • when does the symptoms happen
     • example: the patient experiences a heavy feeling in the head at night and symptoms seem worse first thing in the morning
4. quality
   • explains the signs and symptoms(dull, heavy, sharp, stabbing….)
     • example: The patient describes the pain as a dull pain almost like a toothache that wont go away, the throat is beginning to feel a burning sensation more than likely from the drainage patient is experiencing.
5. severity
   • on a scale of 1-10 how bad are the symptoms(you will typically see this for a pain scale)
     • example: on a scale of 1-10 the patient says that her symptoms are a 9
6. associated signs and symptoms
   • any additional signs and symptoms that are not necessarily part of the main chief complaint
     • example: patient expresses that the past 2 days she has felt nauseous patient denies vomiting or diarrhea
7. Context
   • what happens when the symptoms are apparent
     • example:
8. modifying factors
   • this is anything that makes the signs and symptoms worse or better
     • Patient expresses that the symptoms are relieved only during a hot steamy shower, working seems to make it worse as the patient works in a chemical plant(very noisy and bright lights)

ROS (review of systems)

Review of systems is basically an inventory of body systems this is where the provider asks a series of questions to the patient regarding his/her signs and symptoms and chief complaint. the following is a list of the systems included in the ROS

• Constitutional
• Eyes
• ™Ears, nose, mouth, throat
• ™Cardiovascular
• ™Respiratory
• ™Gastrointestinal
• ™Genitourinary
• ™Musculoskeletal
• ™Integumentary (skin and/or breast)
• ™Neurological
• ™Psychiatric
• ™Endocrine
• ™Hematologic/lymphatic
• ™Allergic/immunologic

PFSH(past family social history)

this section will include any relative family history, social history includes marital status, and alcohol, smoking, recreational drug usage…

MEDICAL DECISION MAKING

The work that goes into the patient visit, any labs ordered that needs to be reviewed, any medication changes, any risk to the patient,if the problems are worsening or improving

Conclusion

Evaluation and management is a complex section of procedural coding and this is the focus of many medical audits! Medical Coders want to be well versed in E/M coding to be successful.